Provider Demographics
NPI:1174955470
Name:HEIDE, NATHAN JOSEPH (DAOM LAC)
Entity type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:JOSEPH
Last Name:HEIDE
Suffix:
Gender:M
Credentials:DAOM LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:656 CHARNELTON STREET
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401
Mailing Address - Country:US
Mailing Address - Phone:541-653-8692
Mailing Address - Fax:541-653-8789
Practice Address - Street 1:656 CHARNELTON STREET
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401
Practice Address - Country:US
Practice Address - Phone:541-653-8692
Practice Address - Fax:541-653-8789
Is Sole Proprietor?:No
Enumeration Date:2013-08-08
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR164157171100000X
CA21349171100000X
ORAC164157171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR154326OtherNCCAOM CERTIFICATE
OR164157OtherOREGON ACUPUNCTURE LICENSE
CA21349OtherCALIFORNIA ACUPUNCTURE LICENSE