Provider Demographics
NPI:1194560177
Name:KOSALEK, NATHANIEL JAMES (PTA)
Entity type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:JAMES
Last Name:KOSALEK
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 BERK RD
Mailing Address - Street 2:
Mailing Address - City:LEESPORT
Mailing Address - State:PA
Mailing Address - Zip Code:19533-8705
Mailing Address - Country:US
Mailing Address - Phone:610-376-4841
Mailing Address - Fax:
Practice Address - Street 1:1011 BERK RD
Practice Address - Street 2:
Practice Address - City:LEESPORT
Practice Address - State:PA
Practice Address - Zip Code:19533-8705
Practice Address - Country:US
Practice Address - Phone:610-376-4841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-01
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATEI006207225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant