Provider Demographics
NPI:1578810123
Name:WALL, NATHAN RANDALL (DC)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:RANDALL
Last Name:WALL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12197 S. DRAPER GATE DR.
Mailing Address - Street 2:STE. 108
Mailing Address - City:SILVERDALE
Mailing Address - State:UT
Mailing Address - Zip Code:98383-8301
Mailing Address - Country:US
Mailing Address - Phone:801-590-0600
Mailing Address - Fax:801-590-0643
Practice Address - Street 1:12197 S DRAPER GATE DR
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-8078
Practice Address - Country:US
Practice Address - Phone:801-590-0600
Practice Address - Fax:801-590-0643
Is Sole Proprietor?:No
Enumeration Date:2012-08-13
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6145802-1202111NP0017X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NP0017XChiropractic ProvidersChiropractorPediatric Chiropractor