Provider Demographics
NPI:1548489511
Name:LANTZ, JASON PAUL (PT ATC)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:PAUL
Last Name:LANTZ
Suffix:
Gender:M
Credentials:PT ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 MIDDLE COUNTRY ROAD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787
Mailing Address - Country:US
Mailing Address - Phone:631-382-4043
Mailing Address - Fax:631-382-4043
Practice Address - Street 1:222 MIDDLE COUNTRY ROAD
Practice Address - Street 2:SUITE 201
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787
Practice Address - Country:US
Practice Address - Phone:631-382-4043
Practice Address - Fax:631-382-4043
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0222471225100000X
NY001072-12255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Not Answered2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2307910OtherUNITED HEALTHCARE
NYQ14A21Medicare ID - Type Unspecified