Provider Demographics
NPI:1356127765
Name:ABEYTA, ALEXANDER JONATHAN (DPT)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:JONATHAN
Last Name:ABEYTA
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 1:8259 WICKER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373-8878
Mailing Address - Country:US
Mailing Address - Phone:800-341-1703
Mailing Address - Fax:877-719-4609
Practice Address - Street 1:5 BON AIR RD STE 129
Practice Address - Street 2:
Practice Address - City:LARKSPUR
Practice Address - State:CA
Practice Address - Zip Code:94939-1139
Practice Address - Country:US
Practice Address - Phone:415-924-8900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-01
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA304785225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA304785OtherPT BOARD OF CALIFORNIA