Healthcare Provider Details

I. General information

NPI: 1033856489
Provider Name (Legal Business Name): ANTHONY LOPER PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2022
Last Update Date: 05/17/2022
Certification Date: 05/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12449 HIGHWAY 49 STE C
GULFPORT MS
39503-2983
US

IV. Provider business mailing address

325 MADISON AVE
WIGGINS MS
39577-3336
US

V. Phone/Fax

Practice location:
  • Phone: 228-872-6836
  • Fax:
Mailing address:
  • Phone: 601-723-0245
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: