Provider Demographics
NPI:1992270417
Name:COUNSELLOR, NATHAN DOUGLAS (PA-C)
Entity type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:DOUGLAS
Last Name:COUNSELLOR
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:408 SHEPPARD AVE
Mailing Address - Street 2:
Mailing Address - City:RUNNEMEDE
Mailing Address - State:NJ
Mailing Address - Zip Code:08078-1523
Mailing Address - Country:US
Mailing Address - Phone:856-371-7214
Mailing Address - Fax:
Practice Address - Street 1:201 HADDON AVE
Practice Address - Street 2:
Practice Address - City:HADDON TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08108-2860
Practice Address - Country:US
Practice Address - Phone:856-854-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-11
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00497400363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant