Provider Demographics
NPI:1275183923
Name:FANT, NATHAN TRAVIS
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:TRAVIS
Last Name:FANT
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 1:5629 WOOLWICH LN NW
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-6914
Mailing Address - Country:US
Mailing Address - Phone:678-478-7542
Mailing Address - Fax:
Practice Address - Street 1:4550 COBB PARKWAY NORTH NW STE 101
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-4181
Practice Address - Country:US
Practice Address - Phone:770-917-8140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-16
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN239986363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner