Healthcare Provider Details

I. General information

NPI: 1376171298
Provider Name (Legal Business Name): NATHAN VICKNAIR STUDENT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2020
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 W 16TH ST
PUEBLO CO
81003-2745
US

IV. Provider business mailing address

216 W 10TH AVE STE 202
KENNEWICK WA
99336-6304
US

V. Phone/Fax

Practice location:
  • Phone: 719-584-4000
  • Fax:
Mailing address:
  • Phone: 509-221-5510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number352219
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: