Healthcare Provider Details

I. General information

NPI: 1134350416
Provider Name (Legal Business Name): SHIRLEY CORTES TAN P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2009
Last Update Date: 08/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

451 W LOCKE ST
ASHDOWN AR
71822-3325
US

IV. Provider business mailing address

451 W LOCKE ST
ASHDOWN AR
71822-3325
US

V. Phone/Fax

Practice location:
  • Phone: 870-898-4115
  • Fax: 870-898-4130
Mailing address:
  • Phone: 870-898-4115
  • Fax: 870-898-4130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 1686
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: