Provider Demographics
NPI:1154456804
Name:SANTOS, JASON ANTONE (MPT)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:ANTONE
Last Name:SANTOS
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 GREENFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANSELMO
Mailing Address - State:CA
Mailing Address - Zip Code:94960-2416
Mailing Address - Country:US
Mailing Address - Phone:415-457-4454
Mailing Address - Fax:415-457-4944
Practice Address - Street 1:220 GREENFIELD AVE
Practice Address - Street 2:
Practice Address - City:SAN ANSELMO
Practice Address - State:CA
Practice Address - Zip Code:94960-2416
Practice Address - Country:US
Practice Address - Phone:415-457-4454
Practice Address - Fax:415-457-4944
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT. 32713225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PT327130Medicare ID - Type Unspecified