Provider Demographics
NPI:1104080118
Name:EARHART, RONALD (PT)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:
Last Name:EARHART
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:657 E COTTONWOOD ST
Mailing Address - Street 2:STE 3D
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-4407
Mailing Address - Country:US
Mailing Address - Phone:928-214-2836
Mailing Address - Fax:928-214-2837
Practice Address - Street 1:77 W FOREST AVE
Practice Address - Street 2:301
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-1479
Practice Address - Country:US
Practice Address - Phone:928-214-2836
Practice Address - Fax:928-214-2837
Is Sole Proprietor?:No
Enumeration Date:2008-07-18
Last Update Date:2021-03-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ5294225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ825458Medicaid
AZ77510Medicare PIN