Basic Information
| Provider Information | |||||||||
| NPI: | 1811287725 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENTZ | ||||||||
| FirstName: | NATHAN | ||||||||
| MiddleName: | TODD | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BENTZ | ||||||||
| OtherFirstName: | NATE | ||||||||
| OtherMiddleName: | T | ||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CRNA | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3333 EVERGREEN DR NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495259493 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163644200 | ||||||||
| FaxNumber: | 6163647347 | ||||||||
| Practice Location | |||||||||
| Address1: | 3333 EVERGREEN DR NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495259493 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163644200 | ||||||||
| FaxNumber: | 6163647347 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2011 | ||||||||
| LastUpdateDate: | 07/03/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 4704256155 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.