MEDICARE: MR. JOSHUA BURSON P.T.A.

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	2395	AR
2	225200000X	Physical Therapy Assistant	2053502	TX
3	225200000X	Physical Therapy Assistant	A6771R	LA

General Provider Information

NPI Number	:	1912246836
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOSHUA BURSON P.T.A.

Provider Business Mailing Address
First Line	:	6168 PIERCE MANSE LOOP
Second Line	:
City	:	BENTON
State	:	AR
Zip	:	72019-8577
Country	:	US
Telephone Number	:	318-780-7879
Fax Number	:

Provider Business Practice Location Address
First Line	:	501 JACK STEPHENS DR # 626
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72205-5551
Country	:	US
Telephone Number	:	501-526-2225
Fax Number	:

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

Provider Enumeration Date	:	02/13/2013
Last Update Date	:	02/13/2013

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