Provider Demographics
NPI:1871128058
Name:VANDERWOUDE, NATHAN (DPT)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:VANDERWOUDE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:655 S WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03103-5714
Mailing Address - Country:US
Mailing Address - Phone:800-995-2673
Mailing Address - Fax:
Practice Address - Street 1:23 CEDAR RIDGE DR
Practice Address - Street 2:
Practice Address - City:SKOWHEGAN
Practice Address - State:ME
Practice Address - Zip Code:04976-4160
Practice Address - Country:US
Practice Address - Phone:207-474-9686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-08
Last Update Date:2020-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY007781225100000X
NY043826225100000X
MEPT5558225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist