Provider Demographics
NPI:1184120016
Name:RUPAR, JET NIALLE (LMT, CMLDT, EP-C)
Entity type:Individual
Prefix:
First Name:JET
Middle Name:NIALLE
Last Name:RUPAR
Suffix:
Gender:X
Credentials:LMT, CMLDT, EP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7500 BROOKTREE RD STE 117
Mailing Address - Street 2:
Mailing Address - City:WEXFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15090-9285
Mailing Address - Country:US
Mailing Address - Phone:724-513-5853
Mailing Address - Fax:
Practice Address - Street 1:7500 BROOKTREE RD STE 117
Practice Address - Street 2:
Practice Address - City:WEXFORD
Practice Address - State:PA
Practice Address - Zip Code:15090-9285
Practice Address - Country:US
Practice Address - Phone:724-591-8228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-31
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG010937225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
14230140OtherCAQH