Provider Demographics
NPI:1194252916
Name:ELLEDGE, NATHAN ROBERT (DO)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:ROBERT
Last Name:ELLEDGE
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 1:896 BIRCHWOOD CT
Mailing Address - Street 2:
Mailing Address - City:HANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:93230-1504
Mailing Address - Country:US
Mailing Address - Phone:559-940-2868
Mailing Address - Fax:
Practice Address - Street 1:400 W MINERAL KING AVE
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291-6237
Practice Address - Country:US
Practice Address - Phone:559-624-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A18996207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology