Provider Demographics
NPI:1275607640
Name:SMITH, NATHAN WARREN (LPTA)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:WARREN
Last Name:SMITH
Suffix:
Gender:M
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4115 EA 240 NORTH
Mailing Address - Street 2:
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442-5879
Mailing Address - Country:US
Mailing Address - Phone:208-745-1422
Mailing Address - Fax:
Practice Address - Street 1:4115 EA 240 NO
Practice Address - Street 2:
Practice Address - City:RIGBY
Practice Address - State:ID
Practice Address - Zip Code:83442-5879
Practice Address - Country:US
Practice Address - Phone:208-745-1422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPTA-180225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant