=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689245888
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LANCE MCTAGGART PTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2021
-----------------------------------------------------
Last Update Date | 07/08/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1900, 77 NORTH EXPRESSWAY K
-----------------------------------------------------
City | BROWNSVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-541-2102
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 71 NOLA RD
-----------------------------------------------------
City | SONTAG
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39665-5518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 7076
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------