Provider Demographics
NPI:1235993478
Name:AMAYUN, NATHAN CLARENCE
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:CLARENCE
Last Name:AMAYUN
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 1:188 E SOUTHWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-3650
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:188 E SOUTHWAY BLVD
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-3650
Practice Address - Country:US
Practice Address - Phone:765-453-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-08
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28231543A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily