Provider Demographics
NPI:1104406586
Name:HOLLISTER, NATHANIEL CHARLES (MD)
Entity type:Individual
Prefix:DR
First Name:NATHANIEL
Middle Name:CHARLES
Last Name:HOLLISTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 RANCHO LN STE 135
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-3826
Mailing Address - Country:US
Mailing Address - Phone:702-383-7885
Mailing Address - Fax:
Practice Address - Street 1:5330 S HIGHWAY 95
Practice Address - Street 2:
Practice Address - City:FORT MOHAVE
Practice Address - State:AZ
Practice Address - Zip Code:86426-9225
Practice Address - Country:US
Practice Address - Phone:928-788-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-10
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ73509207P00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program