Provider Demographics
NPI:1053043281
Name:GLICK, NATHANIEL W
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:W
Last Name:GLICK
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 1:1741 E EDEN PL
Mailing Address - Street 2:
Mailing Address - City:ST FRANCIS
Mailing Address - State:WI
Mailing Address - Zip Code:53235-3644
Mailing Address - Country:US
Mailing Address - Phone:920-858-9978
Mailing Address - Fax:
Practice Address - Street 1:1741 E EDEN PL
Practice Address - Street 2:
Practice Address - City:ST FRANCIS
Practice Address - State:WI
Practice Address - Zip Code:53235-3644
Practice Address - Country:US
Practice Address - Phone:920-858-9978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-27
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty