Provider Demographics
NPI:1720727753
Name:NIX DIRECT ACCESS PEDIATRICS PC
Entity type:Organization
Organization Name:NIX DIRECT ACCESS PEDIATRICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KIJANA
Authorized Official - Middle Name:N
Authorized Official - Last Name:NIX
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-823-5999
Mailing Address - Street 1:10274 LAKE ARBOR WAY STE 201
Mailing Address - Street 2:
Mailing Address - City:MITCHELLVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20721-3146
Mailing Address - Country:US
Mailing Address - Phone:301-823-5999
Mailing Address - Fax:301-823-5990
Practice Address - Street 1:10274 LAKE ARBOR WAY STE 201
Practice Address - Street 2:
Practice Address - City:MITCHELLVILLE
Practice Address - State:MD
Practice Address - Zip Code:20721-3146
Practice Address - Country:US
Practice Address - Phone:301-823-5999
Practice Address - Fax:301-823-5990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-27
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD319072200Medicaid
MD1043368756OtherNPI