Provider Demographics
NPI:1386788941
Name:HANTAVIS, JASON P (MSPT, CSCS, OCS)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:P
Last Name:HANTAVIS
Suffix:
Gender:M
Credentials:MSPT, CSCS, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:489 WASHINGTON ST
Mailing Address - Street 2:STE 200
Mailing Address - City:AUBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01501-5709
Mailing Address - Country:US
Mailing Address - Phone:774-696-8309
Mailing Address - Fax:508-721-0100
Practice Address - Street 1:489 WASHINGTON ST
Practice Address - Street 2:SUITE 200
Practice Address - City:AUBURN
Practice Address - State:MA
Practice Address - Zip Code:01501-5709
Practice Address - Country:US
Practice Address - Phone:508-721-0000
Practice Address - Fax:508-721-0100
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA16986225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY68375OtherBLUE CROSS ID
MAY68375OtherBLUE CROSS ID