Provider Demographics
NPI:1518760131
Name:SOUTHWICK, NATHAN
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:SOUTHWICK
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 52
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:WA
Mailing Address - Zip Code:99343-0052
Mailing Address - Country:US
Mailing Address - Phone:509-528-8583
Mailing Address - Fax:
Practice Address - Street 1:22210 N GLADE RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:WA
Practice Address - Zip Code:99343-7000
Practice Address - Country:US
Practice Address - Phone:509-521-2507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-29
Last Update Date:2025-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA7236-9440-4108146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic