Provider Demographics
NPI:1659821445
Name:LUNDBERG, JONATHAN
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:LUNDBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 INNOVATION DR
Mailing Address - Street 2:
Mailing Address - City:BLAIRSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15717-8096
Mailing Address - Country:US
Mailing Address - Phone:724-343-4060
Mailing Address - Fax:724-343-4069
Practice Address - Street 1:71 NORTH JUNIATA STREET
Practice Address - Street 2:
Practice Address - City:LEWISTOWN
Practice Address - State:PA
Practice Address - Zip Code:17044-2049
Practice Address - Country:US
Practice Address - Phone:717-953-9643
Practice Address - Fax:717-953-9661
Is Sole Proprietor?:No
Enumeration Date:2016-10-05
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT025186225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1019541330001Medicaid
PA396749Medicare PIN