Provider Demographics
NPI:1598072332
Name:STOUT, NATHAN A
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:A
Last Name:STOUT
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 1:7655 S 2700 W
Mailing Address - Street 2:APT. B
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84084-3803
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7655 S 2700 W
Practice Address - Street 2:APT. B
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84084-3803
Practice Address - Country:US
Practice Address - Phone:801-540-0688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-31
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT69840251702390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program