Healthcare Provider Details

I. General information

NPI: 1326685991
Provider Name (Legal Business Name): NIKOLAI X LINCAVAGE CST, SA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2019
Last Update Date: 03/22/2024
Certification Date: 03/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29277 US HIGHWAY 19 N # 29277
CLEARWATER FL
33761-2102
US

IV. Provider business mailing address

29277 US HIGHWAY 19 N # 29277
CLEARWATER FL
33761-2102
US

V. Phone/Fax

Practice location:
  • Phone: 727-313-4764
  • Fax:
Mailing address:
  • Phone: 727-313-4764
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number19-469
License Number State
# 3
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number19-469
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: