Provider Demographics
NPI:1770714115
Name:VANDERBURG, NATHAN DAVID (LMT)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:DAVID
Last Name:VANDERBURG
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6395 KEIZER STATION BLVD NE
Mailing Address - Street 2:
Mailing Address - City:KEIZER
Mailing Address - State:OR
Mailing Address - Zip Code:97303-2305
Mailing Address - Country:US
Mailing Address - Phone:503-589-1597
Mailing Address - Fax:503-586-0299
Practice Address - Street 1:6395 KEIZER STATION BLVD NE
Practice Address - Street 2:
Practice Address - City:KEIZER
Practice Address - State:OR
Practice Address - Zip Code:97303-2305
Practice Address - Country:US
Practice Address - Phone:503-589-1597
Practice Address - Fax:503-586-0299
Is Sole Proprietor?:No
Enumeration Date:2009-08-03
Last Update Date:2009-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13684174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist