Provider Demographics
NPI:1902857311
Name:NESHAT, SUZANNE (PT)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:NESHAT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 N EL CAMINO REAL
Mailing Address - Street 2:#210
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-2811
Mailing Address - Country:US
Mailing Address - Phone:760-634-0248
Mailing Address - Fax:760-634-1782
Practice Address - Street 1:4060 4TH AVE
Practice Address - Street 2:#105
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2116
Practice Address - Country:US
Practice Address - Phone:619-299-5246
Practice Address - Fax:619-299-5751
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 15992225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT15992EOtherMEDICARE PTAN