Healthcare Provider Details

I. General information

NPI: 1750192845
Provider Name (Legal Business Name): NATHAN ALLEN SANNER CAA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2025
Last Update Date: 01/16/2025
Certification Date: 01/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WYOMING ST
DAYTON OH
45409-2722
US

IV. Provider business mailing address

30 BLANC LN APT 204
SPRINGBORO OH
45066-9856
US

V. Phone/Fax

Practice location:
  • Phone: 937-208-6173
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number67.000535
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: