Healthcare Provider Details

I. General information

NPI: 1336600782
Provider Name (Legal Business Name): NICKOLAS ALLAN SULLIVAN HIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2019
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6630 S MCCARRAN BLVD
RENO NV
89509-6145
US

IV. Provider business mailing address

6630 S MCCARRAN BLVD
RENO NV
89509-6145
US

V. Phone/Fax

Practice location:
  • Phone: 775-323-5566
  • Fax:
Mailing address:
  • Phone: 775-323-5566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number14000056727
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberHAS4474TEMPORARY
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: