Provider Demographics
NPI:1275045726
Name:HANCOCK, NICHOLAS WYATT (LAC MTCM)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:WYATT
Last Name:HANCOCK
Suffix:
Gender:M
Credentials:LAC MTCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 HIDDEN VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:SOQUEL
Mailing Address - State:CA
Mailing Address - Zip Code:95073-9708
Mailing Address - Country:US
Mailing Address - Phone:360-259-9757
Mailing Address - Fax:
Practice Address - Street 1:222 OAK MEADOW DR STE B
Practice Address - Street 2:
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-4458
Practice Address - Country:US
Practice Address - Phone:408-399-7711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-24
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17729171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist