Provider Demographics
NPI:1982957924
Name:KORANTENG, NATHAN (ACNP-BC)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:KORANTENG
Suffix:
Gender:M
Credentials:ACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 64442
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4442
Mailing Address - Country:US
Mailing Address - Phone:410-328-8040
Mailing Address - Fax:443-462-3514
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201
Practice Address - Country:US
Practice Address - Phone:410-328-8040
Practice Address - Fax:410-328-0177
Is Sole Proprietor?:No
Enumeration Date:2012-10-15
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR235680363L00000X
AZAP4672363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX294316YMAFMedicare UPIN
TXP01342582Medicare Oscar/Certification
TXP01342582Medicare Oscar/Certification
TX75-2616977-042OtherTRICARE
TX327343502Medicaid