Basic Information
| Provider Information | |||||||||
| NPI: | 1407268154 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GILLISPIE | ||||||||
| FirstName: | NATHANIEL | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 771 PILOT HOUSE DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | NEWPORT NEWS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236061990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7578732302 | ||||||||
| FaxNumber: | 7578732306 | ||||||||
| Practice Location | |||||||||
| Address1: | 77 MARKET ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | PALMYRA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229634687 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4345107301 | ||||||||
| FaxNumber: | 4345107418 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2014 | ||||||||
| LastUpdateDate: | 03/17/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2305208671 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | C05954 | 01 | VA | MEDICARE GROUP PTAN | OTHER |