Provider Demographics
NPI:1861628430
Name:CONDIE, NATHAN CLYDE (DO)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:CLYDE
Last Name:CONDIE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:804 SERVICE RD STE A109B
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824-7015
Mailing Address - Country:US
Mailing Address - Phone:517-884-8701
Mailing Address - Fax:517-884-8787
Practice Address - Street 1:4660 S HAGADORN RD STE 500
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-6804
Practice Address - Country:US
Practice Address - Phone:517-884-8701
Practice Address - Fax:517-884-8787
Is Sole Proprietor?:No
Enumeration Date:2009-06-09
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT362864-1204208100000X, 208100000X
MI5101018410208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1861528430Medicaid
MI1861528430Medicaid