Basic Information
Provider Information | |||||||||
NPI: | 1265898589 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NAMATHEP | ||||||||
FirstName: | NIDA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PTA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 6570 | ||||||||
Address2: |   | ||||||||
City: | PEORIA | ||||||||
State: | AZ | ||||||||
PostalCode: | 853856570 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6233988072 | ||||||||
FaxNumber: | 6233988235 | ||||||||
Practice Location | |||||||||
Address1: | 6036 N 19TH AVE | ||||||||
Address2: |   | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850152106 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6027958441 | ||||||||
FaxNumber: | 6027958447 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/04/2016 | ||||||||
LastUpdateDate: | 01/04/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 11261A | AZ | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |   |
No ID Information.