MEDICARE: NATHAN JENTZSCH RN

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	163WD0400X	Diabetes Educator Registered Nurse	10690070-3102	UT

General Provider Information

NPI Number	:	1730753195
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NATHAN JENTZSCH RN

Provider Business Mailing Address
First Line	:	395 W COUGAR BLVD STE 401
Second Line	:
City	:	PROVO
State	:	UT
Zip	:	84604-3338
Country	:	US
Telephone Number	:	801-357-7747
Fax Number	:

Provider Business Practice Location Address
First Line	:	395 W COUGAR BLVD STE 401
Second Line	:
City	:	PROVO
State	:	UT
Zip	:	84604-3338
Country	:	US
Telephone Number	:	801-357-7747
Fax Number	:

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

Provider Enumeration Date	:	05/19/2021
Last Update Date	:	05/19/2021

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