Provider Demographics
NPI:1467035758
Name:FOSS, NATHANIEL (DPT)
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:
Last Name:FOSS
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 1:4971 N IDLEWILD AVE
Mailing Address - Street 2:
Mailing Address - City:WHITEFISH BAY
Mailing Address - State:WI
Mailing Address - Zip Code:53217-5969
Mailing Address - Country:US
Mailing Address - Phone:414-364-1658
Mailing Address - Fax:
Practice Address - Street 1:7224 118TH AVE STE E
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-8424
Practice Address - Country:US
Practice Address - Phone:262-857-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-04
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15351-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist