Provider Demographics
NPI:1083469142
Name:NATHAN, SAMUEL R (PA-S)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:R
Last Name:NATHAN
Suffix:
Gender:M
Credentials:PA-S
Other - Prefix:
Other - First Name:SAMUEL
Other - Middle Name:R
Other - Last Name:NATHAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-S
Mailing Address - Street 1:PO BOX 955534
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-5534
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:801 MEDICAL DR STE 400
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-3824
Practice Address - Country:US
Practice Address - Phone:636-332-8455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-22
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024027697363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant