Provider Demographics
NPI:1407421241
Name:ANTOM, STEPHEN JOHN (PTA)
Entity Type:Individual
Prefix:
First Name:STEPHEN JOHN
Middle Name:
Last Name:ANTOM
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2235 E FLAMINGO RD STE 170
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-5186
Mailing Address - Country:US
Mailing Address - Phone:702-893-3333
Mailing Address - Fax:702-893-0960
Practice Address - Street 1:2235 E FLAMINGO RD STE 170
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-5186
Practice Address - Country:US
Practice Address - Phone:702-893-3333
Practice Address - Fax:702-893-0960
Is Sole Proprietor?:No
Enumeration Date:2021-05-24
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVA1330225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant