Provider Demographics
NPI:1265652846
Name:SUMNER, NATHAN SHANE (MD)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:SHANE
Last Name:SUMNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81MDOS/SGOMU
Mailing Address - Street 2:301 FISHER STREET STE 1F-130
Mailing Address - City:KEESLER AFB
Mailing Address - State:MS
Mailing Address - Zip Code:39534-2519
Mailing Address - Country:US
Mailing Address - Phone:228-376-3791
Mailing Address - Fax:
Practice Address - Street 1:81MDOS/SGOMU
Practice Address - Street 2:301 FISHER STREET STE 1F-130
Practice Address - City:KEESLER AFB
Practice Address - State:MS
Practice Address - Zip Code:39534-2519
Practice Address - Country:US
Practice Address - Phone:228-376-3791
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ALMD.287442084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program