Provider Demographics
NPI:1952975963
Name:BRAGG, NATHAN
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:BRAGG
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:PO BOX 396
Mailing Address - Street 2:
Mailing Address - City:COWEN
Mailing Address - State:WV
Mailing Address - Zip Code:26206-0396
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:42 EDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:COWEN
Practice Address - State:WV
Practice Address - Zip Code:26206-1177
Practice Address - Country:US
Practice Address - Phone:304-644-7060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-14
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker