Provider Demographics
NPI:1114545159
Name:SNOW, JUSTIN (PT)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:SNOW
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 LINNIE CT
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:NM
Mailing Address - Zip Code:87015-9125
Mailing Address - Country:US
Mailing Address - Phone:505-286-7838
Mailing Address - Fax:505-286-8025
Practice Address - Street 1:1 LINNIE CT
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:NM
Practice Address - Zip Code:87015-9125
Practice Address - Country:US
Practice Address - Phone:505-286-7838
Practice Address - Fax:505-286-8025
Is Sole Proprietor?:No
Enumeration Date:2020-07-07
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPT5721208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation