Provider Demographics
NPI:1366107682
Name:MARINO, NICHOLAS JACK JR (CPNP-AC)
Entity type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:JACK
Last Name:MARINO
Suffix:JR
Gender:M
Credentials:CPNP-AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 MARYANN RD
Mailing Address - Street 2:
Mailing Address - City:TALLMADGE
Mailing Address - State:OH
Mailing Address - Zip Code:44278-1803
Mailing Address - Country:US
Mailing Address - Phone:330-608-3863
Mailing Address - Fax:
Practice Address - Street 1:109 MARYANN RD
Practice Address - Street 2:
Practice Address - City:TALLMADGE
Practice Address - State:OH
Practice Address - Zip Code:44278-1803
Practice Address - Country:US
Practice Address - Phone:330-608-3863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-02
Last Update Date:2025-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0030147363LA2100X, 363LP0200X
OH0030147363LP0222X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0222XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics, Critical Care
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0476233Medicaid