Healthcare Provider Details

I. General information

NPI: 1336551449
Provider Name (Legal Business Name): NICHOLAS SOLOVIEFF PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2014
Last Update Date: 03/14/2021
Certification Date: 03/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 BELMONT ST
WORCESTER MA
01605-2903
US

IV. Provider business mailing address

119 BELMONT ST
WORCESTER MA
01605-2903
US

V. Phone/Fax

Practice location:
  • Phone: 508-334-5603
  • Fax:
Mailing address:
  • Phone: 508-334-5603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA5105
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: