Provider Demographics
NPI:1376190843
Name:O'NEILL, NATHAN (DPT)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:O'NEILL
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 1:101 TOWER RD STE 120
Mailing Address - Street 2:
Mailing Address - City:DAKOTA DUNES
Mailing Address - State:SD
Mailing Address - Zip Code:57049-5011
Mailing Address - Country:US
Mailing Address - Phone:605-217-4320
Mailing Address - Fax:605-217-2948
Practice Address - Street 1:12499 UNIVERSITY AVE STE 250
Practice Address - Street 2:
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-8271
Practice Address - Country:US
Practice Address - Phone:515-985-7530
Practice Address - Fax:515-985-7531
Is Sole Proprietor?:No
Enumeration Date:2019-08-20
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA095574225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1114141546Medicaid