Provider Demographics
NPI:1902355522
Name:LILLARD, TRAVIS EUGENE (PTA)
Entity Type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:EUGENE
Last Name:LILLARD
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 1:134 BLAIR TRL
Mailing Address - Street 2:
Mailing Address - City:POCAHONTAS
Mailing Address - State:AR
Mailing Address - Zip Code:72455-7920
Mailing Address - Country:US
Mailing Address - Phone:870-378-3425
Mailing Address - Fax:
Practice Address - Street 1:31 CHOCTAW CENTER
Practice Address - Street 2:
Practice Address - City:CHEROKEE VILLAGE
Practice Address - State:AR
Practice Address - Zip Code:72529
Practice Address - Country:US
Practice Address - Phone:870-856-4325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-23
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA1749225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant