Provider Demographics
NPI:1609312123
Name:DAVIDSEN, NATHAN (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:DAVIDSEN
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9152 HADWAY DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-1068
Mailing Address - Country:US
Mailing Address - Phone:317-605-0078
Mailing Address - Fax:
Practice Address - Street 1:220 LAKEVIEW DR
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060-1210
Practice Address - Country:US
Practice Address - Phone:317-776-1061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-07
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36003172A2255A2300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer