MEDICARE: NATHAN DREW WIBISONO PT, 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	1377813	TX

General Provider Information

NPI Number	:	1922782606
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NATHAN DREW WIBISONO PT, DPT

Provider Business Mailing Address
First Line	:	221 CHESTNUT LN
Second Line	:
City	:	COPPELL
State	:	TX
Zip	:	75019-2113
Country	:	US
Telephone Number	:	469-556-8553
Fax Number	:

Provider Business Practice Location Address
First Line	:	4701 W PARKER RD # 625
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75093-3376
Country	:	US
Telephone Number	:	972-398-2555
Fax Number	:

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

Provider Enumeration Date	:	06/13/2023
Last Update Date	:	06/13/2023

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