Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225100000X | Physical Therapist | 5063 | AZ |
Y | 2251E1300X | Electrophysiology, Clinical | 109306 | AK |
NPI | 1861466484 |
---|---|
Provider Name | Mr. Nathan R. Shields |
First Address | Wasilla, AK 99687-3895 |
Second Address | Wasilla, AK 99654 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/02/2006 |
Last Update Date | 18/09/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1651715 | (05) | AK |