Provider Demographics
NPI:1639213044
Name:STICE, NATHAN DANIEL (MD)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:DANIEL
Last Name:STICE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 PARK ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-1759
Mailing Address - Country:US
Mailing Address - Phone:270-781-5111
Mailing Address - Fax:270-780-0466
Practice Address - Street 1:201 PARK ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-1759
Practice Address - Country:US
Practice Address - Phone:270-781-5111
Practice Address - Fax:270-780-0466
Is Sole Proprietor?:No
Enumeration Date:2007-02-18
Last Update Date:2014-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KYTP243207V00000X
KY43657207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000670633OtherANTHEM
KY7100124340Medicaid
KY000000670633OtherANTHEM