Provider Demographics
NPI:1285803783
Name:DECKER, MICHAEL WAYNE (PTA)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:WAYNE
Last Name:DECKER
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 ALTA VISTA ST
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71913-6910
Mailing Address - Country:US
Mailing Address - Phone:501-515-1119
Mailing Address - Fax:979-241-6841
Practice Address - Street 1:100 W GORE ST
Practice Address - Street 2:SUITE 301
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1044
Practice Address - Country:US
Practice Address - Phone:407-254-2558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-28
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2061599225200000X
AR2111225200000X
MT1356225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant