Provider Demographics
NPI:1518539527
Name:PRUS, NATHAN WYATT (DPT)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:WYATT
Last Name:PRUS
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 1:59A BEAGLE CLUB RD
Mailing Address - Street 2:
Mailing Address - City:PILESGROVE
Mailing Address - State:NJ
Mailing Address - Zip Code:08098-3028
Mailing Address - Country:US
Mailing Address - Phone:856-264-8528
Mailing Address - Fax:
Practice Address - Street 1:3708 MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:MD
Practice Address - Zip Code:21122-2025
Practice Address - Country:US
Practice Address - Phone:410-255-4833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-11
Last Update Date:2021-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD28416225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist