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General NPI Number Information
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NPI Number | 1205191269
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Entity Type | Individual
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Provider Name | COLTON JUDSON PUCKETT PTA
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Gender | Male
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Dates
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Enumeration Date | 07/05/2012
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Last Update Date | 07/05/2012
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Provider Practice Location Address
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Address Line | 395 COUNTY ROAD 3101
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City | CLARKSVILLE
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State | TX
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Zip | 75426-6905
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Country | US
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Telephone | 903-249-0386
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Fax | 903-427-8256
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Provider Business Mailing Address
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Address Line | 395 COUNTY ROAD 3101
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City | CLARKSVILLE
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State | TX
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Zip | 75426-6905
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Country | US
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Telephone | 903-249-0386
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Fax | 903-427-8256
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 2080660
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License Number State | TX
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