Provider Demographics
NPI:1942562764
Name:DUSTIN, KEVIN M (DPT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:DUSTIN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 PLEASANT DR
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:PA
Mailing Address - Zip Code:16365-3348
Mailing Address - Country:US
Mailing Address - Phone:570-878-9354
Mailing Address - Fax:
Practice Address - Street 1:2265 MARKET STREET
Practice Address - Street 2:SUITE A
Practice Address - City:WARREN
Practice Address - State:PA
Practice Address - Zip Code:16365-4682
Practice Address - Country:US
Practice Address - Phone:814-726-9050
Practice Address - Fax:814-726-9629
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-08
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT022117225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA246650JNGOtherMEDICARE