Provider Demographics
NPI:1922419076
Name:DARST, NATHAN WADE
Entity Type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:WADE
Last Name:DARST
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 1:525 E BUFFALO ST
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:OK
Mailing Address - Zip Code:73736-1177
Mailing Address - Country:US
Mailing Address - Phone:580-554-7833
Mailing Address - Fax:
Practice Address - Street 1:525 E BUFFALO ST
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:OK
Practice Address - Zip Code:73736-1177
Practice Address - Country:US
Practice Address - Phone:580-554-7833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-12
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2706042101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral