Provider Demographics
NPI:1891389128
Name:SUPTIC, JOHN ANTHONY
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ANTHONY
Last Name:SUPTIC
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 1:1905 SWEENEYSBURG RD
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-9705
Mailing Address - Country:US
Mailing Address - Phone:304-575-2393
Mailing Address - Fax:
Practice Address - Street 1:4036 ROBERT C BYRD DR
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-2204
Practice Address - Country:US
Practice Address - Phone:304-575-2393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-26
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant