Provider Demographics
NPI:1487254082
Name:KYSER, JUSTIN WAYNE (PTA)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:WAYNE
Last Name:KYSER
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 COAL ST
Mailing Address - Street 2:
Mailing Address - City:SANDROCK
Mailing Address - State:AL
Mailing Address - Zip Code:35983-4385
Mailing Address - Country:US
Mailing Address - Phone:256-844-0723
Mailing Address - Fax:
Practice Address - Street 1:2301 RAINBOW DR
Practice Address - Street 2:
Practice Address - City:GADSDEN
Practice Address - State:AL
Practice Address - Zip Code:35901-5517
Practice Address - Country:US
Practice Address - Phone:256-543-3467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-01
Last Update Date:2020-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTA9612225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant