Provider Demographics
NPI:1861116675
Name:ATHELSTONE, JEREMY
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:ATHELSTONE
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 1:1608 TREASURE LK
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-9043
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 FIELD HOUSE RD
Practice Address - Street 2:
Practice Address - City:SLIPPERY ROCK
Practice Address - State:PA
Practice Address - Zip Code:16057
Practice Address - Country:US
Practice Address - Phone:800-778-9111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-27
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program