Provider Demographics
NPI:1841940087
Name:ANTONINKA, MEGAN JEWELL (PTA)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:JEWELL
Last Name:ANTONINKA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:328 ELM TREE DR
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-0223
Mailing Address - Country:US
Mailing Address - Phone:573-821-3369
Mailing Address - Fax:
Practice Address - Street 1:328 ELM TREE DR
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-0223
Practice Address - Country:US
Practice Address - Phone:573-821-3369
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-28
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020036130225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant