MEDICARE: MRS. TRESA NIST PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	01646	OH

General Provider Information

NPI Number	:	1205237021
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TRESA NIST PTA

Provider Business Mailing Address
First Line	:	6125 SPANGLER DR
Second Line	:
City	:	NEW FRANKLIN
State	:	OH
Zip	:	44216-8949
Country	:	US
Telephone Number	:	330-882-3052
Fax Number	:

Provider Business Practice Location Address
First Line	:	6125 SPANGLER DR
Second Line	:
City	:	NEW FRANKLIN
State	:	OH
Zip	:	44216-8949
Country	:	US
Telephone Number	:	330-882-3052
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/11/2014
Last Update Date	:	09/11/2014

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