Healthcare Provider Details

I. General information

NPI: 1518159904
Provider Name (Legal Business Name): NATHAN PAUL PRUSS P.T.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2007
Last Update Date: 08/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5575 KINGSLEY RD
CLYDE MI
48049-1003
US

IV. Provider business mailing address

5575 KINGSLEY RD
CLYDE MI
48049-1003
US

V. Phone/Fax

Practice location:
  • Phone: 810-324-2073
  • Fax: 810-324-2073
Mailing address:
  • Phone: 810-324-2073
  • Fax: 810-324-2073

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: