Provider Demographics
NPI:1982050894
Name:STAVAST, JOHN (DPT)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:STAVAST
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 1:526 W CENTER ST STE 105
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062-3359
Mailing Address - Country:US
Mailing Address - Phone:801-899-3814
Mailing Address - Fax:
Practice Address - Street 1:526 W CENTER ST STE 105
Practice Address - Street 2:
Practice Address - City:PLEASANT GROVE
Practice Address - State:UT
Practice Address - Zip Code:84062-3359
Practice Address - Country:US
Practice Address - Phone:801-899-3814
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-10
Last Update Date:2024-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12427493-24012251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic