Healthcare Provider Details

I. General information

NPI: 1831843770
Provider Name (Legal Business Name): NICHOLAS TODD NOBLE PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2022
Last Update Date: 01/26/2023
Certification Date: 01/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 TOWN AND COUNTRY LN
HAZARD KY
41701-9524
US

IV. Provider business mailing address

PO BOX 1988
HAZARD KY
41702-1988
US

V. Phone/Fax

Practice location:
  • Phone: 606-439-1300
  • Fax: 606-439-1400
Mailing address:
  • Phone: 606-439-1300
  • Fax: 606-439-1400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberTC354
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: