Provider Demographics
NPI:1306191911
Name:DAGGETT, NATHAN CHARLES (LMT)
Entity Type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:CHARLES
Last Name:DAGGETT
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1903 ALABAMA ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-1414
Mailing Address - Country:US
Mailing Address - Phone:503-477-0460
Mailing Address - Fax:
Practice Address - Street 1:1903 ALABAMA ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-1414
Practice Address - Country:US
Practice Address - Phone:503-477-0460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-19
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR18487171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR18487OtherMASSAGE LICENSE