Provider Demographics
NPI:1457591216
Name:WOOTEN, NATHANIEL ERIC III (MD)
Entity Type:Individual
Prefix:DR
First Name:NATHANIEL
Middle Name:ERIC
Last Name:WOOTEN
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6355
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59771-6355
Mailing Address - Country:US
Mailing Address - Phone:406-451-4148
Mailing Address - Fax:
Practice Address - Street 1:4580 CONESTOGA CIR
Practice Address - Street 2:SUITE A
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-9216
Practice Address - Country:US
Practice Address - Phone:406-451-4148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-05
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMED-PHYS-LIC-7999174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTB58788Medicare UPIN