Provider Demographics
NPI:1679072078
Name:PECK, NATHAN FRANK (ATC)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:FRANK
Last Name:PECK
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 1:123 LOMAX ST
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-7112
Mailing Address - Country:US
Mailing Address - Phone:803-381-8810
Mailing Address - Fax:
Practice Address - Street 1:123 LOMAX ST
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-7112
Practice Address - Country:US
Practice Address - Phone:803-381-8810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-12
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLAT-26562255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCYPYW16309194OtherBCBS