Healthcare Provider Details

I. General information

NPI: 1740629500
Provider Name (Legal Business Name): MR. MAURICE NICHOLAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2013
Last Update Date: 10/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 NEW BERN AVE
RALEIGH NC
27610-1231
US

IV. Provider business mailing address

337 FLATROCK LN
HOLLY SPRINGS NC
27540-7419
US

V. Phone/Fax

Practice location:
  • Phone: 919-350-8000
  • Fax:
Mailing address:
  • Phone: 919-285-4175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number218800
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: