Provider Demographics
NPI:1376137620
Name:OLDMIXON, NATHAN THOMAS
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:THOMAS
Last Name:OLDMIXON
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 1:3518 HASTINGS LN
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-3315
Mailing Address - Country:US
Mailing Address - Phone:228-697-4292
Mailing Address - Fax:
Practice Address - Street 1:3518 HASTINGS LN
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-3315
Practice Address - Country:US
Practice Address - Phone:228-697-4292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-26
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR857616163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine