Provider Demographics
NPI:1811155112
Name:MANN, NATHAN ANDREW (DO)
Entity type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:ANDREW
Last Name:MANN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 SIXTH ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2386
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:825 N CENTER AVE
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-1592
Practice Address - Country:US
Practice Address - Phone:989-731-7996
Practice Address - Fax:989-731-9151
Is Sole Proprietor?:No
Enumeration Date:2008-05-23
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101018681207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOF96004OtherMEDICARE GROUP PTAN