Provider Demographics
NPI:1760144810
Name:MCCORMACK, NATHAN DANIEL (PT, DPT)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:DANIEL
Last Name:MCCORMACK
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1460 STATE ST
Mailing Address - Street 2:
Mailing Address - City:HOBART
Mailing Address - State:IN
Mailing Address - Zip Code:46342-6076
Mailing Address - Country:US
Mailing Address - Phone:765-810-6298
Mailing Address - Fax:
Practice Address - Street 1:502 E 1100 N
Practice Address - Street 2:
Practice Address - City:CHESTERTON
Practice Address - State:IN
Practice Address - Zip Code:46304-9697
Practice Address - Country:US
Practice Address - Phone:219-926-5850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05014345A2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty