=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841410552
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NATHANIEL R DUBACH P.T.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2007
-----------------------------------------------------
Last Update Date | 10/16/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 159 W 1ST ST
-----------------------------------------------------
City | OSWEGO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13126-2045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-342-9575
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5930 LANDON RD
-----------------------------------------------------
City | EATON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13334-3161
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-750-0087
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 021466-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------