Provider Demographics
NPI:1245865088
Name:NESRSTA, ANGIE (PT)
Entity type:Individual
Prefix:
First Name:ANGIE
Middle Name:
Last Name:NESRSTA
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 1:137 BROADMOOR ST
Mailing Address - Street 2:
Mailing Address - City:MEADOWLAKES
Mailing Address - State:TX
Mailing Address - Zip Code:78654-6622
Mailing Address - Country:US
Mailing Address - Phone:214-208-4750
Mailing Address - Fax:
Practice Address - Street 1:608 GATEWAY CENTRAL
Practice Address - Street 2:
Practice Address - City:MARBLE FALLS
Practice Address - State:TX
Practice Address - Zip Code:78654-6354
Practice Address - Country:US
Practice Address - Phone:830-428-3044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-11
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1131399208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty