Provider Demographics
NPI:1902307184
Name:NISTALA, PRATYUSHA (PT)
Entity Type:Individual
Prefix:
First Name:PRATYUSHA
Middle Name:
Last Name:NISTALA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 W 29TH ST RM 3R
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-5574
Mailing Address - Country:US
Mailing Address - Phone:212-736-8900
Mailing Address - Fax:212-736-8158
Practice Address - Street 1:227 W 29TH ST RM 3R
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-5574
Practice Address - Country:US
Practice Address - Phone:212-736-8900
Practice Address - Fax:212-736-8158
Is Sole Proprietor?:No
Enumeration Date:2018-02-23
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040300-12081P0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPediatric Rehabilitation Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
Z2459030OtherPASSPORT