Provider Demographics
NPI:1194202275
Name:FIELDS, JUSTIN LANCE (PTA, BS)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:LANCE
Last Name:FIELDS
Suffix:
Gender:M
Credentials:PTA, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 E HAWKINS PKWY APT 6304
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-8143
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:406 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WINNSBORO
Practice Address - State:TX
Practice Address - Zip Code:75494-3226
Practice Address - Country:US
Practice Address - Phone:903-342-6790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-23
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2138895225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant