Provider Demographics
NPI:1104715770
Name:ANTANAITIS, ALEC MARSHALL
Entity type:Individual
Prefix:MR
First Name:ALEC
Middle Name:MARSHALL
Last Name:ANTANAITIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1523 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:ADEL
Mailing Address - State:IA
Mailing Address - Zip Code:50003-1028
Mailing Address - Country:US
Mailing Address - Phone:725-260-9420
Mailing Address - Fax:
Practice Address - Street 1:1000 W LINCOLN WAY
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:IA
Practice Address - Zip Code:50129-1685
Practice Address - Country:US
Practice Address - Phone:515-386-2114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-30
Last Update Date:2025-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAH184694363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology