Provider Demographics
NPI:1285907139
Name:HARDGRAVE, NICHOLAS JON (OD)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:JON
Last Name:HARDGRAVE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 290702
Mailing Address - Street 2:
Mailing Address - City:YIGO
Mailing Address - State:GU
Mailing Address - Zip Code:96929-3041
Mailing Address - Country:US
Mailing Address - Phone:671-486-4090
Mailing Address - Fax:
Practice Address - Street 1:36TH MEDICAL GROUP-ANDERSEN AFB CLINIC/OPTOMETRY
Practice Address - Street 2:UNIT 14010
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96543-4003
Practice Address - Country:US
Practice Address - Phone:671-366-6749
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-22
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2733152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist