Healthcare Provider Details

I. General information

NPI: 1356952865
Provider Name (Legal Business Name): NATHAN LOUIS SLADE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2020
Last Update Date: 08/12/2020
Certification Date: 08/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10701 MAIN ST
FAIRFAX VA
22030-6904
US

IV. Provider business mailing address

2911 DEER HOLLOW WAY UNIT 418
FAIRFAX VA
22031-6048
US

V. Phone/Fax

Practice location:
  • Phone: 703-273-7705
  • Fax:
Mailing address:
  • Phone: 757-903-1411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2306605670
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: