Healthcare Provider Details

I. General information

NPI: 1598333189
Provider Name (Legal Business Name): NATHANIEL LOGAN MYERS CAA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2021
Last Update Date: 04/09/2026
Certification Date: 04/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1235 E CHEROKEE ST
SPRINGFIELD MO
65804-2203
US

IV. Provider business mailing address

6205 WILLIAMSBURG WAY APT 102
DEFOREST WI
53532-9123
US

V. Phone/Fax

Practice location:
  • Phone: 417-820-6863
  • Fax:
Mailing address:
  • Phone: 937-728-1860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number190-17
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number190-17
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number2024036980
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: