Provider Demographics
NPI:1700676152
Name:EDWARDS, NATHAN ALLAN
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:ALLAN
Last Name:EDWARDS
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 1:1048 BAXTER ST
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-1916
Mailing Address - Country:US
Mailing Address - Phone:541-968-4472
Mailing Address - Fax:
Practice Address - Street 1:1601 SW JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97331-8656
Practice Address - Country:US
Practice Address - Phone:541-737-3424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-08
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPI-0014545390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program