Healthcare Provider Details

I. General information

NPI: 1376134502
Provider Name (Legal Business Name): NATHAN CHARLES CRAIG PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2021
Last Update Date: 01/31/2021
Certification Date: 01/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 MIX AVE
HAMDEN CT
06514
US

IV. Provider business mailing address

135 EAST AVE 3
WEST HAVEN CT
06516
US

V. Phone/Fax

Practice location:
  • Phone: 203-281-3500
  • Fax:
Mailing address:
  • Phone: 203-980-4157
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number001798
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: