Healthcare Provider Details

I. General information

NPI: 1619545829
Provider Name (Legal Business Name): NATHAN A GLADDEN NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: NATHAN ALAN GLADDEN NP

II. Dates (important events)

Enumeration Date: 06/14/2021
Last Update Date: 07/19/2021
Certification Date: 07/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 WOOD DUCK LN
LAKE VILLAGE AR
71653-7590
US

IV. Provider business mailing address

103 WOOD DUCK LN
LAKE VILLAGE AR
71653-7590
US

V. Phone/Fax

Practice location:
  • Phone: 870-538-7225
  • Fax:
Mailing address:
  • Phone: 870-538-7225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number216314
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number216314
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: