Basic Information
| Provider Information | |||||||||
| NPI: | 1629500285 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLIOTT | ||||||||
| FirstName: | NATHANIEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1001 S. OHIO ST | ||||||||
| Address2: | |||||||||
| City: | SALINA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 67401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7858276453 | ||||||||
| FaxNumber: | 7858231255 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 S. OHIO ST | ||||||||
| Address2: | |||||||||
| City: | SALINA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 67401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7858276453 | ||||||||
| FaxNumber: | 7858231255 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2017 | ||||||||
| LastUpdateDate: | 03/18/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 15-01988 | KS | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 201198520A | 05 | KS | MEDICAID |