Provider Demographics
NPI:1922480722
Name:FIELDING, NATHANIEL LOUIS (PA-C)
Entity type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:LOUIS
Last Name:FIELDING
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 775513
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-5513
Mailing Address - Country:US
Mailing Address - Phone:618-622-7546
Mailing Address - Fax:
Practice Address - Street 1:331 REGENCY PARK
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1887
Practice Address - Country:US
Practice Address - Phone:618-622-7546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-29
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1125480363A00000X
IL085006510363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant