=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700361664
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILLIAM AUSTIN KEITH PTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2018
-----------------------------------------------------
Last Update Date | 09/26/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3030 PINE ST
-----------------------------------------------------
City | ARKADELPHIA
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71923-5325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-246-8623
-----------------------------------------------------
Fax | 870-246-8694
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3030 PINE ST
-----------------------------------------------------
City | ARKADELPHIA
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71923-5325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-246-8623
-----------------------------------------------------
Fax | 870-246-8694
-----------------------------------------------------
=====================================================
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 | PTA4087
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------