Healthcare Provider Details

I. General information

NPI: 1497916738
Provider Name (Legal Business Name): NATHANIEL R POULIN M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2008
Last Update Date: 08/29/2023
Certification Date: 08/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 E BOULDER ST STE 500
COLORADO SPRINGS CO
80909-5533
US

IV. Provider business mailing address

1400 E BOULDER ST STE 500
COLORADO SPRINGS CO
80909-5533
US

V. Phone/Fax

Practice location:
  • Phone: 719-364-6487
  • Fax: 719-364-6488
Mailing address:
  • Phone: 719-364-6487
  • Fax: 719-364-6488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2012-01113
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberDR.0070626
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number2012-01113
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number2012-01113
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License NumberDR.0070626
License Number StateCO
# 6
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberDR.0070626
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: