Provider Demographics
NPI:1407553837
Name:IOB, NATHANIEL
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:
Last Name:IOB
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 1:5564 SCHUTTA RD
Mailing Address - Street 2:
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-4945
Mailing Address - Country:US
Mailing Address - Phone:612-227-8068
Mailing Address - Fax:
Practice Address - Street 1:1011 MEADOWLANDS DR, WHITE BEAR
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55127
Practice Address - Country:US
Practice Address - Phone:612-315-1976
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-15
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician