Provider Demographics
NPI:1174904114
Name:WISSINK, NATHANIEL ALLAN (PT, DPT, MATCS)
Entity type:Individual
Prefix:DR
First Name:NATHANIEL
Middle Name:ALLAN
Last Name:WISSINK
Suffix:
Gender:M
Credentials:PT, DPT, MATCS
Other - Prefix:DR
Other - First Name:NATE
Other - Middle Name:
Other - Last Name:WISSINK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT, DPT, MATCS
Mailing Address - Street 1:9015 ARBOR ST STE 155
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-2072
Mailing Address - Country:US
Mailing Address - Phone:402-580-1606
Mailing Address - Fax:
Practice Address - Street 1:9015 ARBOR ST STE 155
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68124-2072
Practice Address - Country:US
Practice Address - Phone:402-580-1606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-16
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE3465225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE099668015Medicare PIN
NE099668Medicare PIN