Provider Demographics
NPI:1740812684
Name:ROSENBAUM, NATHANIEL RYAN (DPT)
Entity type:Individual
Prefix:DR
First Name:NATHANIEL
Middle Name:RYAN
Last Name:ROSENBAUM
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3255 STONEBRIDGE CT APT 5
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-4708
Mailing Address - Country:US
Mailing Address - Phone:269-369-2031
Mailing Address - Fax:
Practice Address - Street 1:2800 NILES RD
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-3317
Practice Address - Country:US
Practice Address - Phone:269-408-1990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-09
Last Update Date:2020-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501019470225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist