Provider Demographics
NPI:1063049815
Name:RUH, NICOLE BOSHNAKOV (MD/MBA)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:BOSHNAKOV
Last Name:RUH
Suffix:
Gender:F
Credentials:MD/MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4494 NORTH PALMER ROAD
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20889-0001
Mailing Address - Country:US
Mailing Address - Phone:301-295-9283
Mailing Address - Fax:301-295-5928
Practice Address - Street 1:MOBILE DIVE AND SALVAGE UNIT ONE MEDICAL DEPARTMENT
Practice Address - Street 2:BLDG 17 BISHOP POINT
Practice Address - City:PEARL HARBOR
Practice Address - State:HI
Practice Address - Zip Code:96860
Practice Address - Country:US
Practice Address - Phone:716-955-0476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-23
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0101274671208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program