=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942201330
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HERBERT JAMES HUSTON PHYSICIAN ASSISTANT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2005
-----------------------------------------------------
Last Update Date | 05/15/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 404 N PLEASANT AVE
-----------------------------------------------------
City | CENTRALIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62801-3006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-339-9872
-----------------------------------------------------
Fax | 618-533-6816
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 404 N PLEASANT AVE
-----------------------------------------------------
City | CENTRALIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62801-3006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-339-9872
-----------------------------------------------------
Fax | 618-533-6816
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 085-001637
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------