Healthcare Provider Details

I. General information

NPI: 1568725190
Provider Name (Legal Business Name): NATHAN DANIEL WASS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2012
Last Update Date: 05/02/2024
Certification Date: 04/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6490 BLUE STAR HWY
SAUGATUCK MI
49453-0001
US

IV. Provider business mailing address

6490 BLUE STAR HWY
SAUGATUCK MI
49453-0001
US

V. Phone/Fax

Practice location:
  • Phone: 269-857-3208
  • Fax:
Mailing address:
  • Phone: 269-857-3208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101020031
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: