Healthcare Provider Details

I. General information

NPI: 1770273641
Provider Name (Legal Business Name): NATHEN ANDREW PERKINS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2023
Last Update Date: 05/12/2023
Certification Date: 05/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 S FAIRMONT AVE
LODI CA
95240-3958
US

IV. Provider business mailing address

750 SPAANS DR STE F
GALT CA
95632-8609
US

V. Phone/Fax

Practice location:
  • Phone: 209-744-9909
  • Fax: 209-744-9910
Mailing address:
  • Phone: 209-744-9909
  • Fax: 209-744-9910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1507120523
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: