Provider Demographics
NPI:1154176220
Name:LY, NICHOLAS
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:LY
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 1:17601 BRIDGEFARMER BLVD
Mailing Address - Street 2:
Mailing Address - City:PFLUGERVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78660-3482
Mailing Address - Country:US
Mailing Address - Phone:513-413-8118
Mailing Address - Fax:
Practice Address - Street 1:919 E 32ND ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-2703
Practice Address - Country:US
Practice Address - Phone:512-544-7111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-22
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant