Healthcare Provider Details

I. General information

NPI: 1699169474
Provider Name (Legal Business Name): NICHOLAS KRISHNAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2015
Last Update Date: 05/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1103 16TH AVE SE
DECATUR AL
35601-3595
US

IV. Provider business mailing address

1103 16TH AVE SE
DECATUR AL
35601-3595
US

V. Phone/Fax

Practice location:
  • Phone: 256-350-0362
  • Fax: 256-355-9779
Mailing address:
  • Phone: 256-350-0362
  • Fax: 256-355-9779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-1045
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: