Provider Demographics
NPI:1588978274
Name:HAWK, BRIAN E (PTA)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:E
Last Name:HAWK
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:PO BOX 392
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:AR
Mailing Address - Zip Code:72933-0392
Mailing Address - Country:US
Mailing Address - Phone:479-806-3475
Mailing Address - Fax:
Practice Address - Street 1:1919 CHARMONT DRIVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:AR
Practice Address - Zip Code:72933
Practice Address - Country:US
Practice Address - Phone:479-965-6752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-05
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA2436225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant