Provider Demographics
NPI:1356173660
Name:FERGUSON, NATHAN W (MEDIATOR (CERTIFIED))
Entity type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:W
Last Name:FERGUSON
Suffix:
Gender:M
Credentials:MEDIATOR (CERTIFIED)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68-3692 KIMO NUI ST
Mailing Address - Street 2:
Mailing Address - City:WAIKOLOA
Mailing Address - State:HI
Mailing Address - Zip Code:96738-5110
Mailing Address - Country:US
Mailing Address - Phone:808-999-9211
Mailing Address - Fax:
Practice Address - Street 1:4016 3RD ST S UNIT 1077
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-5848
Practice Address - Country:US
Practice Address - Phone:904-325-7379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-15
Last Update Date:2024-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIH01627842172A00000X
FLF622639924570347C00000X
3747P1801X
OKT15574183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183700000XPharmacy Service ProvidersPharmacy Technician
No172A00000XOther Service ProvidersDriverGroup - Single Specialty
No347C00000XTransportation ServicesPrivate VehicleGroup - Single Specialty
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant