Healthcare Provider Details

I. General information

NPI: 1710890140
Provider Name (Legal Business Name): NATHAN SCOTT SOUTHARD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2026
Last Update Date: 09/25/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5563 E CO RD 44 UNIT 6
WILDWOOD FL
34785
US

IV. Provider business mailing address

1221 EMERSON ST
INVERNESS FL
34450-6515
US

V. Phone/Fax

Practice location:
  • Phone: 352-571-4148
  • Fax:
Mailing address:
  • Phone: 352-257-1884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA30054
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: