Provider Demographics
NPI:1548660467
Name:MITCHELL, NATHAN
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42644 COUNTY ROAD 653
Mailing Address - Street 2:
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079-9471
Mailing Address - Country:US
Mailing Address - Phone:269-312-9966
Mailing Address - Fax:
Practice Address - Street 1:42644 COUNTY ROAD 653
Practice Address - Street 2:
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079-9471
Practice Address - Country:US
Practice Address - Phone:269-312-9966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-27
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501000965174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist