Provider Demographics
NPI:1790865228
Name:THORESON, NATHANIEL SCOTT (PT)
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:SCOTT
Last Name:THORESON
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 1:1132 E POLSTON AVE
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-6045
Mailing Address - Country:US
Mailing Address - Phone:208-777-7800
Mailing Address - Fax:208-777-9209
Practice Address - Street 1:1132 E POLSTON AVE
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-6045
Practice Address - Country:US
Practice Address - Phone:208-777-7800
Practice Address - Fax:208-777-9209
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT1354174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010025022OtherREGENCE BLUE SHIELD
IDT3548OtherBLUE CROSS
WA126619OtherWASHINGTON L&I
IDP00155553OtherRAILROAD MEDICARE
ID14490OtherGROUP HEALTH
IDT3548OtherBLUE CROSS