Provider Demographics
NPI:1083188536
Name:DEGROOD, NICHOLAS
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:DEGROOD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4315 GOLF CLUB DR APT 5808
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:AL
Mailing Address - Zip Code:36830-5894
Mailing Address - Country:US
Mailing Address - Phone:952-607-7471
Mailing Address - Fax:
Practice Address - Street 1:2316 WALKER BLD
Practice Address - Street 2:
Practice Address - City:AUBURN UNIVERSITY
Practice Address - State:AL
Practice Address - Zip Code:36849-0001
Practice Address - Country:US
Practice Address - Phone:952-607-7471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-17
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS12441390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program