Basic Information
| Provider Information | |||||||||
| NPI: | 1023745577 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JEFFERSON | ||||||||
| FirstName: | AUSTIN | ||||||||
| MiddleName: | TYLER | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9118 | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554809118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8656940062 | ||||||||
| FaxNumber: | 8656947907 | ||||||||
| Practice Location | |||||||||
| Address1: | 9430 PARK WEST BLVD STE 230 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379234204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655608550 | ||||||||
| FaxNumber: | 8655608551 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2022 | ||||||||
| LastUpdateDate: | 10/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 14040 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.