Provider Demographics
NPI:1235493081
Name:WILLARD, NATHAN ALEXANDER
Entity Type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:ALEXANDER
Last Name:WILLARD
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 1:363 JANS CT
Mailing Address - Street 2:
Mailing Address - City:CENTRAL POINT
Mailing Address - State:OR
Mailing Address - Zip Code:97502-2529
Mailing Address - Country:US
Mailing Address - Phone:541-414-8488
Mailing Address - Fax:
Practice Address - Street 1:920 TOWN CENTRE DR
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6100
Practice Address - Country:US
Practice Address - Phone:541-414-8488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-26
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR50065834Medicaid