Healthcare Provider Details

I. General information

NPI: 1609312123
Provider Name (Legal Business Name): NATHAN DAVIDSEN ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2017
Last Update Date: 07/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 LAKEVIEW DR
NOBLESVILLE IN
46060-1210
US

IV. Provider business mailing address

9152 HADWAY DR
INDIANAPOLIS IN
46256-1068
US

V. Phone/Fax

Practice location:
  • Phone: 317-776-1061
  • Fax:
Mailing address:
  • Phone: 317-605-0078
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36003172A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: