Provider Demographics
NPI:1699105650
Name:ANTONE, JUSTIN
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:ANTONE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2735
Mailing Address - Street 2:
Mailing Address - City:WINDOW ROCK
Mailing Address - State:AZ
Mailing Address - Zip Code:86515
Mailing Address - Country:US
Mailing Address - Phone:928-245-5935
Mailing Address - Fax:
Practice Address - Street 1:130 JEDDITO COURT
Practice Address - Street 2:
Practice Address - City:WINDOW ROCK
Practice Address - State:AZ
Practice Address - Zip Code:86515
Practice Address - Country:US
Practice Address - Phone:928-245-5935
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-12
Last Update Date:2013-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD02067444343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)