Provider Demographics
NPI:1073874079
Name:FOGARTY, NATHAN WILBERT (DPT)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:WILBERT
Last Name:FOGARTY
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 5TH AVE E APT 206
Mailing Address - Street 2:
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-1261
Mailing Address - Country:US
Mailing Address - Phone:701-721-4229
Mailing Address - Fax:
Practice Address - Street 1:2251 CONNECTICUT AVE S STE 3600
Practice Address - Street 2:
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-2556
Practice Address - Country:US
Practice Address - Phone:320-529-0036
Practice Address - Fax:320-259-0038
Is Sole Proprietor?:No
Enumeration Date:2012-06-06
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT82222312401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist