Provider Demographics
NPI:1134778533
Name:BUBACY, NATHANIEL
Entity type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:
Last Name:BUBACY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 WORCESTER PROVIDENCE TPKE
Mailing Address - Street 2:
Mailing Address - City:SUTTON
Mailing Address - State:MA
Mailing Address - Zip Code:01590-2513
Mailing Address - Country:US
Mailing Address - Phone:508-861-1010
Mailing Address - Fax:
Practice Address - Street 1:64 WORCESTER PROVIDENCE TPKE
Practice Address - Street 2:
Practice Address - City:SUTTON
Practice Address - State:MA
Practice Address - Zip Code:01590-2513
Practice Address - Country:US
Practice Address - Phone:508-861-1010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-09
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA24579225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist