Provider Demographics
NPI:1396153466
Name:LUSK, BENJAMIN (DPT)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:LUSK
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 1:30544 ID-200
Mailing Address - Street 2:STE 326
Mailing Address - City:PONDERAY
Mailing Address - State:ID
Mailing Address - Zip Code:83852
Mailing Address - Country:US
Mailing Address - Phone:208-205-9559
Mailing Address - Fax:808-421-4244
Practice Address - Street 1:30544 ID-200
Practice Address - Street 2:
Practice Address - City:PONDERAY
Practice Address - State:ID
Practice Address - Zip Code:83852
Practice Address - Country:US
Practice Address - Phone:208-205-9559
Practice Address - Fax:808-431-4244
Is Sole Proprietor?:No
Enumeration Date:2014-08-01
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP15158225100000X
ID6229225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist