Healthcare Provider Details

I. General information

NPI: 1801868187
Provider Name (Legal Business Name): NATHANIEL HOLMES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

256 MASON AVE # C
STATEN ISLAND NY
10305-3408
US

IV. Provider business mailing address

PO BOX 23831
NEWARK NJ
07189-0001
US

V. Phone/Fax

Practice location:
  • Phone: 718-226-6398
  • Fax: 718-226-1247
Mailing address:
  • Phone: 973-971-5595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number208C00000X
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: