Provider Demographics
NPI:1174592935
Name:NASTAN, MARY L (RPT)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:L
Last Name:NASTAN
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11808 MARSH HEAD RD
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34240-8883
Mailing Address - Country:US
Mailing Address - Phone:941-378-5249
Mailing Address - Fax:
Practice Address - Street 1:11808 MARSH HEAD RD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34240-8883
Practice Address - Country:US
Practice Address - Phone:941-378-5249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-15
Last Update Date:2011-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22782251P0200X
222Q00000X
FLPT2278225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL880152500Medicaid
FL880152501Medicaid