Healthcare Provider Details

I. General information

NPI: 1174510788
Provider Name (Legal Business Name): NEIL J NATHAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 04/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3471 REGIONAL PKWY
SANTA ROSA CA
95403-8209
US

IV. Provider business mailing address

3471 REGIONAL PKWY
SANTA ROSA CA
95403-8209
US

V. Phone/Fax

Practice location:
  • Phone: 707-575-5180
  • Fax:
Mailing address:
  • Phone: 707-575-5180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR5C40
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: