Provider Demographics
NPI:1205442563
Name:NANULA, PHILIP JAMES JR (PT)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:JAMES
Last Name:NANULA
Suffix:JR
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 1:14580 TAMIAMI TRL UNIT D&E
Mailing Address - Street 2:
Mailing Address - City:NORTH PORT
Mailing Address - State:FL
Mailing Address - Zip Code:34287-2708
Mailing Address - Country:US
Mailing Address - Phone:941-200-2570
Mailing Address - Fax:941-218-5627
Practice Address - Street 1:14580 TAMIAMI TRL UNIT D&E
Practice Address - Street 2:
Practice Address - City:NORTH PORT
Practice Address - State:FL
Practice Address - Zip Code:34287-2708
Practice Address - Country:US
Practice Address - Phone:941-200-2570
Practice Address - Fax:941-218-5627
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-21
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046113225100000X
FL40424225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY06313024Medicaid