Provider Demographics
NPI:1881242303
Name:CANDELARIA, JOHNATHAN TAYLOR
Entity type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:TAYLOR
Last Name:CANDELARIA
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 1:600 SOMERSET AVE
Mailing Address - Street 2:
Mailing Address - City:WINDBER
Mailing Address - State:PA
Mailing Address - Zip Code:15963-1397
Mailing Address - Country:US
Mailing Address - Phone:814-467-3465
Mailing Address - Fax:
Practice Address - Street 1:600 SOMERSET AVE
Practice Address - Street 2:
Practice Address - City:WINDBER
Practice Address - State:PA
Practice Address - Zip Code:15963-1397
Practice Address - Country:US
Practice Address - Phone:814-467-3465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-28
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT027956208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation