Provider Demographics
NPI:1316392137
Name:STALEY, NATHANIEL ORLAND (DO)
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:ORLAND
Last Name:STALEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9700 W LA HONTON DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-0428
Mailing Address - Country:US
Mailing Address - Phone:208-866-2697
Mailing Address - Fax:
Practice Address - Street 1:200 MULLINS DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OR
Practice Address - Zip Code:97355-3983
Practice Address - Country:US
Practice Address - Phone:541-259-0200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-29
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR390200000X
IDO-1507208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program