Provider Demographics
NPI:1922092675
Name:TELLERS, NATHAN MICHAEL (ATC)
Entity Type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:MICHAEL
Last Name:TELLERS
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4246 SPRUCE RD
Mailing Address - Street 2:
Mailing Address - City:ST BONIFACIUS
Mailing Address - State:MN
Mailing Address - Zip Code:55375-1315
Mailing Address - Country:US
Mailing Address - Phone:952-467-1915
Mailing Address - Fax:
Practice Address - Street 1:4246 SPRUCE RD
Practice Address - Street 2:
Practice Address - City:ST BONIFACIUS
Practice Address - State:MN
Practice Address - Zip Code:55375-1315
Practice Address - Country:US
Practice Address - Phone:952-467-1915
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN17452255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer