Provider Demographics
NPI:1104672948
Name:DOUGHERTY, NATHAN (DO)
Entity type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:
Last Name:DOUGHERTY
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 1:612 GARFIELD AVE APT 1012
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64124-2289
Mailing Address - Country:US
Mailing Address - Phone:913-832-0486
Mailing Address - Fax:
Practice Address - Street 1:2301 HOLMES ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64108-2640
Practice Address - Country:US
Practice Address - Phone:816-404-4175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-24
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program