Provider Demographics
NPI:1174726632
Name:MOLDESTAD, NATHAN A (PT)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:A
Last Name:MOLDESTAD
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 8TH AVE NW
Mailing Address - Street 2:SUITE 4
Mailing Address - City:FARIBAULT
Mailing Address - State:MN
Mailing Address - Zip Code:55021-5068
Mailing Address - Country:US
Mailing Address - Phone:507-334-5627
Mailing Address - Fax:507-334-1824
Practice Address - Street 1:200 8TH AVE NW
Practice Address - Street 2:SUITE 4
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-5068
Practice Address - Country:US
Practice Address - Phone:507-334-5627
Practice Address - Fax:507-334-1824
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN7907225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN230D7MOOtherMN BLUE CROSS BLUE SHIELD