MEDICARE: MRS. TIFFANY SMITH PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	PTA1708	AR

General Provider Information

NPI Number	:	1124162631
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TIFFANY SMITH PTA

Provider Business Mailing Address
First Line	:	17706 I30 STE 3
Second Line	:
City	:	BENTON
State	:	AR
Zip	:	72019-2930
Country	:	US
Telephone Number	:	501-315-4414
Fax Number	:	501-315-3467

Provider Business Practice Location Address
First Line	:	17706 I30 STE 3
Second Line	:
City	:	BENTON
State	:	AR
Zip	:	72019-2930
Country	:	US
Telephone Number	:	501-315-4414
Fax Number	:	501-315-3467

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/16/2007
Last Update Date	:	07/08/2007

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Directions to “ MRS. TIFFANY SMITH PTA” Practice Location

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