Provider Demographics
NPI:1679763247
Name:DAVIDSON, NATHAN E (LCPO)
Entity Type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:E
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:LCPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 39TH AVE SW
Mailing Address - Street 2:SUITE D
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-5915
Mailing Address - Country:US
Mailing Address - Phone:253-770-6578
Mailing Address - Fax:253-881-1397
Practice Address - Street 1:812 39TH AVE SW
Practice Address - Street 2:SUITE D
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-5915
Practice Address - Country:US
Practice Address - Phone:253-770-6578
Practice Address - Fax:253-881-1397
Is Sole Proprietor?:No
Enumeration Date:2007-07-30
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOI00000477174400000X
WAPS 60145968174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist