Provider Demographics
NPI:1194387571
Name:PTAK, NATHANIEL A
Entity type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:A
Last Name:PTAK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5750 E HIGHWAY 90 STE 200
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-9113
Mailing Address - Country:US
Mailing Address - Phone:520-263-3761
Mailing Address - Fax:
Practice Address - Street 1:5750 E HIGHWAY 90 STE 200
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-9113
Practice Address - Country:US
Practice Address - Phone:520-263-3761
Practice Address - Fax:520-263-3779
Is Sole Proprietor?:No
Enumeration Date:2019-07-05
Last Update Date:2025-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12366058-0501207XX0004X
AZPOD001108213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery