MEDICARE: MR. NATHANIEL LEE SEXTON DPT

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	225100000X	Physical Therapist	PT5091	MS

General Provider Information

NPI Number	:	1861747560
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. NATHANIEL LEE SEXTON DPT

Provider Business Mailing Address
First Line	:	711 AVIGNON DR
Second Line	:
City	:	RIDGELAND
State	:	MS
Zip	:	39157-5120
Country	:	US
Telephone Number	:	601-605-6777
Fax Number	:	601-607-1553

Provider Business Practice Location Address
First Line	:	6300 E LAKE BLVD STE 101
Second Line	:
City	:	VANCLEAVE
State	:	MS
Zip	:	39565-6771
Country	:	US
Telephone Number	:	228-215-2240
Fax Number	:	228-215-2241

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

Provider Enumeration Date	:	07/18/2012
Last Update Date	:	08/01/2024

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