Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | PT 2980 | ID |
NPI | 1003173360 |
---|---|
Provider Name | Nathan Ira Allen |
First Address | Tigard, OR 97224-7736 |
Second Address | Nampa, ID 83651-6407 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/04/2012 |
Last Update Date | 23/01/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1003173360-000 | (05) | ID |
P01106195 | RR MEDICARE (01) | ID |
P01106202 | RR MEDICARE (01) | ID |