Healthcare Provider Details

I. General information

NPI: 1336107143
Provider Name (Legal Business Name): NORTHEAST PATHOLOGY ASSOCIATES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 07/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1825 LOGAN AVE
WATERLOO IA
50703-1916
US

IV. Provider business mailing address

PO BOX 2818
WATERLOO IA
50704-2818
US

V. Phone/Fax

Practice location:
  • Phone: 319-235-3679
  • Fax: 319-233-0722
Mailing address:
  • Phone: 319-233-3044
  • Fax: 319-233-0722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number State

VIII. Authorized Official

Name: KENT A NICKELL
Title or Position: OWNER
Credential: M.D.
Phone: 319-235-3679