Provider Demographics
NPI:1689699589
Name:KER, NATHAN JOHN
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:JOHN
Last Name:KER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:NATHAN
Other - Middle Name:JOHN
Other - Last Name:KER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:940 E 3RD ST STE 208
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-3251
Mailing Address - Country:US
Mailing Address - Phone:307-312-2726
Mailing Address - Fax:307-216-8391
Practice Address - Street 1:940 E 3RD ST STE 208
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-3251
Practice Address - Country:US
Practice Address - Phone:307-312-2726
Practice Address - Fax:307-216-8391
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY7056A208M00000X, 207Q00000X, 208M00000X
CO49726207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO65086066Medicaid
CO65086066Medicaid