Provider Demographics
NPI:1518204858
Name:PAGE, NATHANIEL JR
Entity type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:
Last Name:PAGE
Suffix:JR
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 1:291 BLUE ELK DR
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-8301
Mailing Address - Country:US
Mailing Address - Phone:580-762-1996
Mailing Address - Fax:
Practice Address - Street 1:200 WHITE EAGLE DR
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-8315
Practice Address - Country:US
Practice Address - Phone:580-765-2501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-07
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker