Provider Demographics
NPI:1154956209
Name:NICOLA, NATHAN D (NP)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:D
Last Name:NICOLA
Suffix:
Gender:M
Credentials:NP
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Mailing Address - Street 1:6920 POINTE INVERNESS WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7934
Mailing Address - Country:US
Mailing Address - Phone:260-479-3516
Mailing Address - Fax:260-479-3520
Practice Address - Street 1:6511 E STATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-7026
Practice Address - Country:US
Practice Address - Phone:260-425-2725
Practice Address - Fax:260-479-4604
Is Sole Proprietor?:No
Enumeration Date:2020-03-10
Last Update Date:2020-10-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN71009821A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily