Provider Demographics
NPI:1427611227
Name:HOGAN, NICHOLAS
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:HOGAN
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 1:1515 FLINT ST
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-4911
Mailing Address - Country:US
Mailing Address - Phone:979-583-7148
Mailing Address - Fax:
Practice Address - Street 1:1515 FLINT ST
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-4911
Practice Address - Country:US
Practice Address - Phone:979-583-7148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-17
Last Update Date:2025-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024049483367500000X
390200000X
AR120419367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program