Provider Demographics
NPI:1699237883
Name:MICHAEL, NICHOLAS
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:MICHAEL
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 1:1500 WESTBRANCH DR APT 671
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22102-3291
Mailing Address - Country:US
Mailing Address - Phone:814-574-6560
Mailing Address - Fax:
Practice Address - Street 1:8901 WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20889-0004
Practice Address - Country:US
Practice Address - Phone:814-574-6560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-05
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0101270245208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program