Healthcare Provider Details

I. General information

NPI: 1518539527
Provider Name (Legal Business Name): NATHAN WYATT PRUS DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2021
Last Update Date: 01/07/2026
Certification Date: 01/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 CENTRAL AVE SE STE D
ALBUQUERQUE NM
87102-4650
US

IV. Provider business mailing address

2001 BUTTERFIELD RD STE 1600
DOWNERS GROVE IL
60515-1211
US

V. Phone/Fax

Practice location:
  • Phone: 505-242-2294
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberCP051940T
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberCP035464T
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number304229
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberJ1-0014919
License Number StateDE
# 5
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberCP031224T
License Number StateDE
# 6
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA02245800
License Number StateNJ
# 7
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number28416
License Number StateMD
# 8
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-2025-0197
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: