Provider Demographics
NPI:1376114819
Name:AUSTIN, ANTHONY
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:AUSTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:ANTHONY
Other - Middle Name:DAMARCO
Other - Last Name:AUSTIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PBT TRANSPORTATION
Mailing Address - Street 1:11414 W PARK PL STE 202
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53224-3500
Mailing Address - Country:US
Mailing Address - Phone:414-979-9993
Mailing Address - Fax:
Practice Address - Street 1:11414 W PARK PL STE 202
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53224-3500
Practice Address - Country:US
Practice Address - Phone:414-979-9993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-06
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIA2350047408401172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver