Provider Demographics
NPI:1518539527
Name:PRUS, NATHAN WYATT (DPT)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:WYATT
Last Name:PRUS
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 1:2001 BUTTERFIELD RD STE 1600
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-1211
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11172 HIGHWAY 142 N
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-2547
Practice Address - Country:US
Practice Address - Phone:678-712-3692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-11
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD28416225100000X
CA304229225100000X
NJ40QA02245800225100000X
DECP031224T225100000X
GACP035464T225100000X
DEJ1-0014919225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist