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General NPI Number Information
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NPI Number | 1922782606
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Entity Type | Individual
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Provider Name | NATHAN DREW WIBISONO PT, DPT
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Gender | Male
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Dates
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Enumeration Date | 06/13/2023
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Last Update Date | 06/13/2023
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Provider Practice Location Address
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Address Line | 4701 W PARKER RD # 625
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City | PLANO
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State | TX
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Zip | 75093-3376
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Country | US
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Telephone | 972-398-2555
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Fax |
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Provider Business Mailing Address
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Address Line | 221 CHESTNUT LN
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City | COPPELL
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State | TX
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Zip | 75019-2113
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Country | US
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Telephone | 469-556-8553
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 1377813
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License Number State | TX
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