Provider Demographics
NPI:1003882242
Name:NATHAN, KERRY (PA)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:
Last Name:NATHAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31150 HOOVER
Mailing Address - Street 2:SUITE B
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093
Mailing Address - Country:US
Mailing Address - Phone:586-983-3666
Mailing Address - Fax:586-983-3776
Practice Address - Street 1:31150 HOOVER
Practice Address - Street 2:SUITE B
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093
Practice Address - Country:US
Practice Address - Phone:586-983-3666
Practice Address - Fax:586-983-3776
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601002908363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q20409Medicare UPIN
MIP24970001Medicare ID - Type Unspecified