Provider Demographics
NPI:1770953267
Name:TODD, NATHAN VINCENT (PA-C)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:VINCENT
Last Name:TODD
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:347 VARICK ST APT 207A
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07302-8406
Mailing Address - Country:US
Mailing Address - Phone:413-478-5609
Mailing Address - Fax:
Practice Address - Street 1:622 W 168TH ST # VC2260
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3720
Practice Address - Country:US
Practice Address - Phone:313-305-2995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-28
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY617742-1163W00000X
CA811691163W00000X
NY023398363A00000X
NJ25MP00626100363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No163W00000XNursing Service ProvidersRegistered Nurse