Healthcare Provider Details

I. General information

NPI: 1215853726
Provider Name (Legal Business Name): IAN BOURNE DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2026
Last Update Date: 06/29/2026
Certification Date: 06/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 ARKANSHIRE CIR
SPRINGDALE AR
72764-2833
US

IV. Provider business mailing address

2621 N EMERALD AVE
FAYETTEVILLE AR
72703-3459
US

V. Phone/Fax

Practice location:
  • Phone: 479-364-6191
  • Fax:
Mailing address:
  • Phone: 501-690-3804
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number4405
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: