Provider Demographics
NPI:1508206244
Name:NORTHUP, NATHAN (MO/HIS)
Entity Type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:
Last Name:NORTHUP
Suffix:
Gender:M
Credentials:MO/HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1306 OLD HIGHWAY 63 S STE B
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-8404
Mailing Address - Country:US
Mailing Address - Phone:573-875-4327
Mailing Address - Fax:
Practice Address - Street 1:1306 OLD HIGHWAY 63 S STE B
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-8404
Practice Address - Country:US
Practice Address - Phone:573-875-4327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-26
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008000047237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist