Provider Demographics
NPI:1821786047
Name:HAIRSTON, VICTOR
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:
Last Name:HAIRSTON
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 1:935 BLANKENSHIP RD APT 8
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-2137
Mailing Address - Country:US
Mailing Address - Phone:910-853-1992
Mailing Address - Fax:
Practice Address - Street 1:935 BLANKENSHIP RD APT 8
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-2137
Practice Address - Country:US
Practice Address - Phone:910-853-1992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-26
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225200000X
VA2306606294225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant