Provider Demographics
NPI:1821455056
Name:ROBERTS, NATHAN THOMAS (MS, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:THOMAS
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 LIBERTY AVE
Mailing Address - Street 2:
Mailing Address - City:ROSETO
Mailing Address - State:PA
Mailing Address - Zip Code:18013-1229
Mailing Address - Country:US
Mailing Address - Phone:610-533-0074
Mailing Address - Fax:
Practice Address - Street 1:501 W LAUREL AVE
Practice Address - Street 2:
Practice Address - City:PEN ARGYL
Practice Address - State:PA
Practice Address - Zip Code:18072-1052
Practice Address - Country:US
Practice Address - Phone:610-863-1293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-19
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0045182255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer