Provider Demographics
NPI:1568078459
Name:YASUTAKE, JUSTIN (DPT)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:YASUTAKE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 MONTGOMERY ST STE 110
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94104-3405
Mailing Address - Country:US
Mailing Address - Phone:415-986-4979
Mailing Address - Fax:
Practice Address - Street 1:220 MONTGOMERY ST STE 110
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94104-3405
Practice Address - Country:US
Practice Address - Phone:415-986-4979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-17
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT298429225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist