Provider Demographics
NPI:1104941491
Name:RODRIGUEZ, NOLAN (MPT)
Entity type:Individual
Prefix:
First Name:NOLAN
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 STEVENS PL
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-3609
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4713 ONONDAGA BLVD.
Practice Address - Street 2:SUITE 100
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13219
Practice Address - Country:US
Practice Address - Phone:315-469-5400
Practice Address - Fax:315-469-5724
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPENDINGMedicare ID - Type Unspecified