Provider Demographics
NPI:1730953340
Name:ALSTON, ERVIN
Entity type:Individual
Prefix:
First Name:ERVIN
Middle Name:
Last Name:ALSTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 FLOYD ST
Mailing Address - Street 2:
Mailing Address - City:FLEMING ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32003-8718
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1021 FLOYD ST
Practice Address - Street 2:
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-8718
Practice Address - Country:US
Practice Address - Phone:904-803-7861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-14
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL33083225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant