Healthcare Provider Details

I. General information

NPI: 1417520503
Provider Name (Legal Business Name): BRANDI GASPARD PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2021
Last Update Date: 07/19/2021
Certification Date: 07/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2425 DAVE WARD DR STE 103
CONWAY AR
72034-8679
US

IV. Provider business mailing address

2425 DAVE WARD DR STE 103
CONWAY AR
72034-8679
US

V. Phone/Fax

Practice location:
  • Phone: 501-327-1730
  • Fax:
Mailing address:
  • Phone: 501-327-1730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number4591
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: