MEDICARE: JONATHAN NATHANIEL HUSTED

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	10266	OH

General Provider Information

NPI Number	:	1972298941
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN NATHANIEL HUSTED

Provider Business Mailing Address
First Line	:	244 BROOKFIELD AVE
Second Line	:
City	:	YOUNGSTOWN
State	:	OH
Zip	:	44512-3446
Country	:	US
Telephone Number	:	330-207-3426
Fax Number	:

Provider Business Practice Location Address
First Line	:	1527 GRANDIN RD SW
Second Line	:
City	:	ROANOKE
State	:	VA
Zip	:	24015-2305
Country	:	US
Telephone Number	:	540-342-9525
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/06/2023
Last Update Date	:	04/06/2023

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