Provider Demographics
NPI:1578276390
Name:SOUHEAVER, NATHAN (DPT)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:SOUHEAVER
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 1:105 MARINER HEALTH WAY STE 213
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-3251
Mailing Address - Country:US
Mailing Address - Phone:904-217-4259
Mailing Address - Fax:904-217-4251
Practice Address - Street 1:105 MARINER HEALTH WAY STE 213
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-3251
Practice Address - Country:US
Practice Address - Phone:904-217-4259
Practice Address - Fax:904-217-4251
Is Sole Proprietor?:No
Enumeration Date:2022-12-27
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
FLPTT39797225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist