Provider Demographics
NPI:1760548085
Name:DAVIDSON, NATHAN E (DC)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:E
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO 88
Mailing Address - Street 2:
Mailing Address - City:BIG LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55309
Mailing Address - Country:US
Mailing Address - Phone:763-263-8433
Mailing Address - Fax:763-263-2963
Practice Address - Street 1:670 HUMBOLDT DRIVE
Practice Address - Street 2:
Practice Address - City:BIG LAKE
Practice Address - State:MN
Practice Address - Zip Code:55309
Practice Address - Country:US
Practice Address - Phone:763-263-8433
Practice Address - Fax:763-263-2963
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3099111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN53159888OtherWAUSAU
MN53159888OtherPATIENT CHOICE
MN59B57N0OtherBLUE CROSS
MN53159888OtherPATIENT CHOICE
MNU53862Medicare UPIN