Basic Information
Provider Information | |||||||||
NPI: | 1922643584 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PANTTAJA | ||||||||
FirstName: | NATHAN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | OD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1395 W LACEY BLVD | ||||||||
Address2: |   | ||||||||
City: | HANFORD | ||||||||
State: | CA | ||||||||
PostalCode: | 932305904 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5595853937 | ||||||||
FaxNumber: | 5595823645 | ||||||||
Practice Location | |||||||||
Address1: | 1395 W LACEY BLVD | ||||||||
Address2: |   | ||||||||
City: | HANFORD | ||||||||
State: | CA | ||||||||
PostalCode: | 932305904 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5595853937 | ||||||||
FaxNumber: | 5595823645 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/07/2019 | ||||||||
LastUpdateDate: | 07/02/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/02/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 34452TLG | CA | Y |   | Eye and Vision Services Providers | Optometrist |   |
No ID Information.