Healthcare Provider Details

I. General information

NPI: 1174486120
Provider Name (Legal Business Name): NATHAN DAVID BANTA LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2025
Last Update Date: 12/06/2025
Certification Date: 12/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9895 SE SUNNYSIDE RD STE K
CLACKAMAS OR
97015-9745
US

IV. Provider business mailing address

2195 NW 18TH AVE APT 652
PORTLAND OR
97209-2478
US

V. Phone/Fax

Practice location:
  • Phone: 503-653-0400
  • Fax:
Mailing address:
  • Phone: 503-660-6845
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number28831
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: