Basic Information
Provider Information
NPI: 1003001140
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: NICASTRO
FirstName: JON
MiddleName:  
NamePrefix: MR.
NameSuffix:  
Credential: PT
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 4441 E LOHMAN AVE
Address2:  
City: LAS CRUCES
State: NM
PostalCode: 880118267
CountryCode: US
TelephoneNumber: 5056367434
FaxNumber:  
Practice Location
Address1: 2205 S MAIN ST
Address2:  
City: LAS CRUCES
State: NM
PostalCode: 880053113
CountryCode: US
TelephoneNumber: 5756523515
FaxNumber: 5756523518
Other Information
ProviderEnumerationDate: 09/12/2007
LastUpdateDate: 10/27/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225100000X4491NMY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist 

No ID Information.


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