Provider Demographics
NPI:1538725130
Name:BACON, NATHAN D (DPT)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:D
Last Name:BACON
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 1:5383 AUSTIN DR
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:IN
Mailing Address - Zip Code:47960-6531
Mailing Address - Country:US
Mailing Address - Phone:812-614-1928
Mailing Address - Fax:765-449-1196
Practice Address - Street 1:307 SAGAMORE PKWY W STE 400
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-1500
Practice Address - Country:US
Practice Address - Phone:765-463-2200
Practice Address - Fax:765-463-3625
Is Sole Proprietor?:No
Enumeration Date:2019-05-20
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05013332A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist