Provider Demographics
NPI:1760414320
Name:NUSSBAUM, LANE MATTHEW (PT)
Entity Type:Individual
Prefix:
First Name:LANE
Middle Name:MATTHEW
Last Name:NUSSBAUM
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2710 E 57TH AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99223-6678
Mailing Address - Country:US
Mailing Address - Phone:509-252-2354
Mailing Address - Fax:509-252-2357
Practice Address - Street 1:2710 E 57TH AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99223-6678
Practice Address - Country:US
Practice Address - Phone:509-252-2354
Practice Address - Fax:509-252-2357
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00009353225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA207659OtherL&I PROVIDER NUMBER