Provider Demographics
NPI:1114957073
Name:KANE, JUSTIN THOMAS (PT)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:THOMAS
Last Name:KANE
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 1:1917 N LAKEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2634
Mailing Address - Country:US
Mailing Address - Phone:208-664-8194
Mailing Address - Fax:208-667-1847
Practice Address - Street 1:1172 W HAYDEN AVE
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-8700
Practice Address - Country:US
Practice Address - Phone:208-762-3332
Practice Address - Fax:208-762-4268
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2009-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-700225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0000100007419OtherBLUE SHIELD
WA0100472OtherWASHINGTON LABOR & INDUST
ID004401801Medicaid
IDT5501OtherBLUE CROSS
ID0000100007419OtherBLUE SHIELD