Provider Demographics
NPI:1467728170
Name:WAAG, NATHAN WILLIAM (PTA)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:WILLIAM
Last Name:WAAG
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:334 52ND AVE
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-4224
Mailing Address - Country:US
Mailing Address - Phone:970-371-8208
Mailing Address - Fax:
Practice Address - Street 1:1700 18TH AVE
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-5134
Practice Address - Country:US
Practice Address - Phone:970-353-3370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-27
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO12057225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant