Provider Demographics
NPI:1932246576
Name:AMILASAN, NASSER C (PT)
Entity type:Individual
Prefix:
First Name:NASSER
Middle Name:C
Last Name:AMILASAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 W PINE ST
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-2020
Mailing Address - Country:US
Mailing Address - Phone:209-368-1009
Mailing Address - Fax:209-368-1024
Practice Address - Street 1:6725 INGLEWOOD AVE
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-3865
Practice Address - Country:US
Practice Address - Phone:209-368-1009
Practice Address - Fax:209-368-1024
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 17823225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00444361OtherRAILROAD MEDICARE PTAN
CAPT 17823OtherSTATE LICENSE