Provider Demographics
NPI:1487081493
Name:KEPHART, NATHANIEL TYLER (DPT)
Entity type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:TYLER
Last Name:KEPHART
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 1:260 1ST AVE S STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4364
Mailing Address - Country:US
Mailing Address - Phone:727-308-9848
Mailing Address - Fax:
Practice Address - Street 1:6775 40TH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33709-4939
Practice Address - Country:US
Practice Address - Phone:727-803-1102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-04
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVPT0032252251X0800X
FLPT34598225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic