Provider Demographics
NPI:1942201330
Name:HUSTON, HERBERT JAMES (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:HERBERT
Middle Name:JAMES
Last Name:HUSTON
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 N PLEASANT AVE
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-3006
Mailing Address - Country:US
Mailing Address - Phone:618-339-9872
Mailing Address - Fax:618-533-6816
Practice Address - Street 1:404 N PLEASANT AVE
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-3006
Practice Address - Country:US
Practice Address - Phone:618-339-9872
Practice Address - Fax:618-533-6816
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-001637363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
K15439Medicare UPIN