Provider Demographics
NPI:1760098669
Name:SYLVESTER, JUSTIN ALAN (PTA)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ALAN
Last Name:SYLVESTER
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 1:2410 SUSANNAH ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-1748
Mailing Address - Country:US
Mailing Address - Phone:423-282-9011
Mailing Address - Fax:
Practice Address - Street 1:2410 SUSANNAH ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-1748
Practice Address - Country:US
Practice Address - Phone:423-282-9011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-17
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6524225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty