Healthcare Provider Details

I. General information

NPI: 1447653092
Provider Name (Legal Business Name): DARIUS JAMAR HAGGANS PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2014
Last Update Date: 09/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3307 N DIXIELAND RD
ROGERS AR
72756
US

IV. Provider business mailing address

15 COUNTY ROAD 779
WYNNE AR
72396-8153
US

V. Phone/Fax

Practice location:
  • Phone: 479-986-5150
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA 2329
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: