Healthcare Provider Details

I. General information

NPI: 1649888751
Provider Name (Legal Business Name): WILLIE EUGENE MCMAHAN JR. PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2020
Last Update Date: 07/15/2020
Certification Date: 07/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1871 FALLS BLVD N
WYNNE AR
72396-4026
US

IV. Provider business mailing address

2010 SFC 858
PALESTINE AR
72372-8431
US

V. Phone/Fax

Practice location:
  • Phone: 870-261-8910
  • Fax:
Mailing address:
  • Phone: 870-261-8910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2756
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: