Provider Demographics
NPI:1386266484
Name:SHORT, RONALD II (PT)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:
Last Name:SHORT
Suffix:II
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:RON
Other - Middle Name:
Other - Last Name:SHORT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:323 E HAWKINS PKWY STE A
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-8162
Mailing Address - Country:US
Mailing Address - Phone:903-758-2746
Mailing Address - Fax:
Practice Address - Street 1:323 E HAWKINS PKWY STE A
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-8162
Practice Address - Country:US
Practice Address - Phone:903-758-2746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-12
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1091114225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist