MEDICARE: NATHAN W FERGUSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183700000X	Pharmacy Technician	T15574	OK
2	172A00000X	Driver	H01627842	HI

General Provider Information

NPI Number	:	1356173660
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NATHAN W FERGUSON

Provider Business Mailing Address
First Line	:	68-3692 KIMO NUI ST
Second Line	:
City	:	WAIKOLOA
State	:	HI
Zip	:	96738-5110
Country	:	US
Telephone Number	:	808-999-9211
Fax Number	:

Provider Business Practice Location Address
First Line	:	68-3916 PANIOLO AVE
Second Line	:
City	:	WAIKOLOA
State	:	HI
Zip	:	96738
Country	:	US
Telephone Number	:	808-883-8434
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/15/2024
Last Update Date	:	08/15/2024

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