Healthcare Provider Details

I. General information

NPI: 1215676812
Provider Name (Legal Business Name): KATHERINE SUZANNE SHORT PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KATHERINE SUZANNE SWANSON SWANSON

II. Dates (important events)

Enumeration Date: 06/01/2022
Last Update Date: 06/01/2022
Certification Date: 06/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2510 W HUDSON RD
ROGERS AR
72756-2072
US

IV. Provider business mailing address

556 KENSINGTON
CAVE SPRINGS AR
72718-5013
US

V. Phone/Fax

Practice location:
  • Phone: 479-936-1061
  • Fax: 855-812-1132
Mailing address:
  • Phone: 479-430-0350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number4700
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: