Provider Demographics
NPI:1720169063
Name:MICHAEL, NATHANIEL B (PT)
Entity Type:Individual
Prefix:MR
First Name:NATHANIEL
Middle Name:B
Last Name:MICHAEL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3311 TOLEDO TER
Mailing Address - Street 2:SUITE #A-1
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20782-4135
Mailing Address - Country:US
Mailing Address - Phone:301-853-0093
Mailing Address - Fax:301-853-0096
Practice Address - Street 1:3311 TOLEDO TER
Practice Address - Street 2:SUITE #A-1
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20782-4135
Practice Address - Country:US
Practice Address - Phone:301-853-0093
Practice Address - Fax:301-853-0096
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD19341174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDNAMedicare ID - Type UnspecifiedPENDING