Healthcare Provider Details

I. General information

NPI: 1073180758
Provider Name (Legal Business Name): NATHANIEL MATTISON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2021
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7500 MERCY RD
OMAHA NE
68124-2319
US

IV. Provider business mailing address

1501 KINGS HWY
SHREVEPORT LA
71103-4228
US

V. Phone/Fax

Practice location:
  • Phone: 402-398-6060
  • Fax:
Mailing address:
  • Phone: 318-626-1036
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number37438
License Number StateNE
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number335094
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: