Healthcare Provider Details

I. General information

NPI: 1083379663
Provider Name (Legal Business Name): NATHAN CLAGG II NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2021
Last Update Date: 09/07/2022
Certification Date: 09/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

936 STATE ROUTE 160
GALLIPOLIS OH
45631-8243
US

IV. Provider business mailing address

PO BOX 390
HUNTINGTON WV
25708-0390
US

V. Phone/Fax

Practice location:
  • Phone: 740-446-4600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number111960
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.0030137
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: