Provider Demographics
NPI:1609964782
Name:VAN NATTA, ROSS B (MSPT)
Entity Type:Individual
Prefix:
First Name:ROSS
Middle Name:B
Last Name:VAN NATTA
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 TOWER DR W
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-7511
Mailing Address - Country:US
Mailing Address - Phone:651-351-6047
Mailing Address - Fax:
Practice Address - Street 1:1700 TOWER DR W
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-7511
Practice Address - Country:US
Practice Address - Phone:651-351-6047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPT02693225100000X
MN7251225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN610978100Medicaid
MN650001039Medicare ID - Type UnspecifiedPART B