Healthcare Provider Details

I. General information

NPI: 1346230083
Provider Name (Legal Business Name): NICHOLAS A POWERS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 02/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12255 DEPAUL DR. SUITE 600
BRIDGETON MO
63044
US

IV. Provider business mailing address

1551 WALL ST SUITE 310
SAINT CHARLES MO
63303-3539
US

V. Phone/Fax

Practice location:
  • Phone: 314-291-1074
  • Fax:
Mailing address:
  • Phone: 636-669-2268
  • Fax: 636-669-2401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2008014592
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: