Provider Demographics
NPI:1407268154
Name:GILLISPIE, NATHANIEL T (PT, DPT)
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:T
Last Name:GILLISPIE
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:771 PILOT HOUSE DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-1990
Mailing Address - Country:US
Mailing Address - Phone:757-873-2302
Mailing Address - Fax:757-873-2306
Practice Address - Street 1:77 MARKET ST
Practice Address - Street 2:SUITE B
Practice Address - City:PALMYRA
Practice Address - State:VA
Practice Address - Zip Code:22963-4687
Practice Address - Country:US
Practice Address - Phone:434-510-7301
Practice Address - Fax:434-510-7418
Is Sole Proprietor?:No
Enumeration Date:2014-05-29
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305208671225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC05954OtherMEDICARE GROUP PTAN