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General NPI Number Information
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NPI Number | 1972298941
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Entity Type | Individual
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Provider Name | JONATHAN NATHANIEL HUSTED
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Gender | Male
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Dates
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Enumeration Date | 04/06/2023
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Last Update Date | 04/06/2023
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Provider Practice Location Address
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Address Line | 1527 GRANDIN RD SW
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City | ROANOKE
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State | VA
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Zip | 24015-2305
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Country | US
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Telephone | 540-342-9525
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Fax |
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Provider Business Mailing Address
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Address Line | 244 BROOKFIELD AVE
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City | YOUNGSTOWN
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State | OH
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Zip | 44512-3446
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Country | US
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Telephone | 330-207-3426
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 10266
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License Number State | OH
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