Provider Demographics
NPI:1548765217
Name:AMEEN, NATHAN THOMS MOON
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:THOMS MOON
Last Name:AMEEN
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 1:104 GLOUCESTER CT
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:NC
Mailing Address - Zip Code:28570
Mailing Address - Country:US
Mailing Address - Phone:252-342-6006
Mailing Address - Fax:
Practice Address - Street 1:73 EAKES DR
Practice Address - Street 2:
Practice Address - City:BUIES CREEK
Practice Address - State:NC
Practice Address - Zip Code:27506
Practice Address - Country:US
Practice Address - Phone:910-893-1327
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-26
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program