Provider Demographics
NPI:1346755618
Name:MINOR, JUSTIN (MPT)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:MINOR
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 1:182 BUTLER ST
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18702-4465
Mailing Address - Country:US
Mailing Address - Phone:570-970-0402
Mailing Address - Fax:570-970-0403
Practice Address - Street 1:182 BUTLER ST
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-4465
Practice Address - Country:US
Practice Address - Phone:570-970-0402
Practice Address - Fax:570-970-0403
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-08
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT021461208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation