Basic Information
| Provider Information | |||||||||
| NPI: | 1467035758 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FOSS | ||||||||
| FirstName: | NATHANIEL | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4971 N IDLEWILD AVE | ||||||||
| Address2: | |||||||||
| City: | WHITEFISH BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532175969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143641658 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7224 118TH AVE STE E | ||||||||
| Address2: | |||||||||
| City: | KENOSHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531428424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2628574400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2021 | ||||||||
| LastUpdateDate: | 05/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 15351-24 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.