Provider Demographics
NPI:1902695562
Name:HAIRSTON, ANTWAN JOHN
Entity type:Individual
Prefix:
First Name:ANTWAN
Middle Name:JOHN
Last Name:HAIRSTON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3677 KARWIN DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45406-3610
Mailing Address - Country:US
Mailing Address - Phone:937-503-0175
Mailing Address - Fax:
Practice Address - Street 1:3677 KARWIN DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45406-3610
Practice Address - Country:US
Practice Address - Phone:937-503-0175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-01
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHTE267711376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker