Provider Demographics
NPI:1609258078
Name:TIMMERMAN, NATHAN
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:TIMMERMAN
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 1:490 N MARLEY ST
Mailing Address - Street 2:
Mailing Address - City:SAINT IGNACE
Mailing Address - State:MI
Mailing Address - Zip Code:49781-1449
Mailing Address - Country:US
Mailing Address - Phone:231-955-8473
Mailing Address - Fax:
Practice Address - Street 1:490 N MARLEY ST
Practice Address - Street 2:
Practice Address - City:SAINT IGNACE
Practice Address - State:MI
Practice Address - Zip Code:49781-1449
Practice Address - Country:US
Practice Address - Phone:231-955-8473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-22
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502002993225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant