Provider Demographics
NPI:1316512015
Name:LUNDBERG, NATHAN TODD (PT, DPT)
Entity type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:TODD
Last Name:LUNDBERG
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 N LOCUST GROVE RD STE 170
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-9379
Mailing Address - Country:US
Mailing Address - Phone:208-917-2660
Mailing Address - Fax:208-917-2630
Practice Address - Street 1:535 N LOCUST GROVE RD STE 170
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-9379
Practice Address - Country:US
Practice Address - Phone:208-917-2660
Practice Address - Fax:208-917-2630
Is Sole Proprietor?:No
Enumeration Date:2021-05-25
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT7243225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID7243OtherSTATE LICENSE