Healthcare Provider Details

I. General information

NPI: 1306507116
Provider Name (Legal Business Name): NATAN THEISE DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2022
Last Update Date: 01/04/2022
Certification Date: 12/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10740 QUEENS BLVD STE 207
FOREST HILLS NY
11375-4252
US

IV. Provider business mailing address

6740 BOOTH ST APT 2A
FOREST HILLS NY
11375-2757
US

V. Phone/Fax

Practice location:
  • Phone: 718-261-3100
  • Fax: 718-261-2915
Mailing address:
  • Phone: 646-420-5149
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number048315
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: