Provider Demographics
NPI:1922782606
Name:WIBISONO, NATHAN DREW (PT, DPT)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:DREW
Last Name:WIBISONO
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 1:221 CHESTNUT LN
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-2113
Mailing Address - Country:US
Mailing Address - Phone:469-556-8553
Mailing Address - Fax:
Practice Address - Street 1:4701 W PARKER RD # 625
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-3376
Practice Address - Country:US
Practice Address - Phone:972-398-2555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-13
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1377813225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist