Provider Demographics
NPI:1356566020
Name:GRAVLEY, NATHAN S (PT)
Entity type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:S
Last Name:GRAVLEY
Suffix:
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 1:3820 CRESTWOOD LN
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-4979
Mailing Address - Country:US
Mailing Address - Phone:208-552-7700
Mailing Address - Fax:
Practice Address - Street 1:1000 HIGHWAY 6
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:UT
Practice Address - Zip Code:84651-1600
Practice Address - Country:US
Practice Address - Phone:801-465-7070
Practice Address - Fax:801-465-7001
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT5991225100000X
UT313219-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist