Provider Demographics
NPI:1336696590
Name:ANDERSON, NATHANIEL
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:NATH
Other - Middle Name:
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:266 E ELM ST
Mailing Address - Street 2:
Mailing Address - City:YARMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04096-7116
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:266 E ELM ST
Practice Address - Street 2:
Practice Address - City:YARMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04096-7116
Practice Address - Country:US
Practice Address - Phone:207-232-9105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-06
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP161101363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology