Provider Demographics
NPI:1053698233
Name:ANTONIO, JASON MATTHEW (DPT)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:MATTHEW
Last Name:ANTONIO
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 1:875 E CANAL DR STE 1
Mailing Address - Street 2:
Mailing Address - City:TURLOCK
Mailing Address - State:CA
Mailing Address - Zip Code:95380-4542
Mailing Address - Country:US
Mailing Address - Phone:209-633-3077
Mailing Address - Fax:209-633-3078
Practice Address - Street 1:875 E CANAL DR STE 1
Practice Address - Street 2:
Practice Address - City:TURLOCK
Practice Address - State:CA
Practice Address - Zip Code:95380
Practice Address - Country:US
Practice Address - Phone:209-633-3077
Practice Address - Fax:209-633-3078
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-15
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37820174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist