Provider Demographics
NPI:1194445932
Name:NICOLAS, JEAN
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:NICOLAS
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 1:2203 MORGANSIDE WAY
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33596-7836
Mailing Address - Country:US
Mailing Address - Phone:813-822-7961
Mailing Address - Fax:
Practice Address - Street 1:2203 MORGANSIDE WAY
Practice Address - Street 2:
Practice Address - City:VALRICO
Practice Address - State:FL
Practice Address - Zip Code:33596-7836
Practice Address - Country:US
Practice Address - Phone:813-822-7961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-31
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLL20000196536343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)