Provider Demographics
NPI:1174486120
Name:BANTA, NATHAN DAVID (LMT)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:DAVID
Last Name:BANTA
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2195 NW 18TH AVE APT 652
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-2478
Mailing Address - Country:US
Mailing Address - Phone:503-660-6845
Mailing Address - Fax:
Practice Address - Street 1:9895 SE SUNNYSIDE RD STE K
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-9745
Practice Address - Country:US
Practice Address - Phone:503-653-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-12-06
Last Update Date:2025-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR28831225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist