Active NPI
Jesse Kusmulyana, PTA
- Physical Therapy Assistant
- Peridot, AZ
National Provider Identifier
1467010082
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physical Therapy Assistant
- License
- PTA-013887
- Practice address
- 103 Medicine Way Rd
Peridot, AZ 85542-5000 - Phone
- (928) 475-1360
- NPI assigned
- May 29, 2019
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physical Therapy Assistant | 225200000X | PTA-013887 | AZ | Primary |
Addresses
Primary practice location
103 Medicine Way Rd
Peridot, AZ 85542-5000
Mailing address
103 Medicine Way Rd
Peridot, AZ 85542-5000
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PTA-013887 | AZ | MD | Physical Therapy Assistant |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1559088000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1559088000000",
"number": "1467010082",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "103 MEDICINE WAY RD",
"city": "PERIDOT",
"state": "AZ",
"postal_code": "855425000"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "103 MEDICINE WAY RD",
"city": "PERIDOT",
"state": "AZ",
"postal_code": "855425000",
"telephone_number": "928-475-1360"
}
],
"practiceLocations": [],
"basic": {
"last_name": "KUSMULYANA",
"first_name": "JESSE",
"credential": "PTA",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2019-05-29",
"last_updated": "2019-05-29",
"status": "A"
},
"taxonomies": [
{
"code": "225200000X",
"taxonomy_group": "",
"desc": "Physical Therapy Assistant",
"state": "AZ",
"license": "PTA-013887",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Peridot, AZ
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 29, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.