Provider Demographics
NPI:1457828766
Name:NYBERG, NATHANIEL
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:
Last Name:NYBERG
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:PO BOX 1234
Mailing Address - Street 2:
Mailing Address - City:SAINT HELENS
Mailing Address - State:OR
Mailing Address - Zip Code:97051-8234
Mailing Address - Country:US
Mailing Address - Phone:503-438-2229
Mailing Address - Fax:
Practice Address - Street 1:58646 MCNULTY WAY
Practice Address - Street 2:
Practice Address - City:SAINT HELENS
Practice Address - State:OR
Practice Address - Zip Code:97051-6210
Practice Address - Country:US
Practice Address - Phone:503-438-2229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-25
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201605370RN163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine