Healthcare Provider Details

I. General information

NPI: 1922887553
Provider Name (Legal Business Name): NICHOLAS JAMES GOLDSACK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2023
Last Update Date: 08/25/2025
Certification Date: 08/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 FERRY ST
HUDSON NH
03051-4215
US

IV. Provider business mailing address

716 STEVENS AVE
PORTLAND ME
04103-2693
US

V. Phone/Fax

Practice location:
  • Phone: 603-759-2251
  • Fax:
Mailing address:
  • Phone: 207-283-0171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: