Provider Demographics
NPI:1871879809
Name:KOEP, NATHAN ALLEN (ATC)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:ALLEN
Last Name:KOEP
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 14TH ST NE
Mailing Address - Street 2:SUITE A
Mailing Address - City:BUFFALO
Mailing Address - State:MN
Mailing Address - Zip Code:55313-2927
Mailing Address - Country:US
Mailing Address - Phone:769-684-3899
Mailing Address - Fax:
Practice Address - Street 1:101 14TH ST NE
Practice Address - Street 2:SUITE A
Practice Address - City:BUFFALO
Practice Address - State:MN
Practice Address - Zip Code:55313-2927
Practice Address - Country:US
Practice Address - Phone:769-684-3899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-21
Last Update Date:2018-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2296174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist