Provider Demographics
NPI:1669027868
Name:MAX, NATHAN
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:MAX
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 1:915 E MARKET AVE
Mailing Address - Street 2:
Mailing Address - City:SEARCY
Mailing Address - State:AR
Mailing Address - Zip Code:72149-5615
Mailing Address - Country:US
Mailing Address - Phone:501-279-5642
Mailing Address - Fax:
Practice Address - Street 1:921 NE 13TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5007
Practice Address - Country:US
Practice Address - Phone:501-733-1089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-05
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OK4561363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program