Healthcare Provider Details

I. General information

NPI: 1245724756
Provider Name (Legal Business Name): NICHOLAS DZUBAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2018
Last Update Date: 06/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 GRAHAM DR
ATHENS OH
45701-1430
US

IV. Provider business mailing address

PO BOX 1595
COLUMBUS OH
43216-1595
US

V. Phone/Fax

Practice location:
  • Phone: 800-321-8293
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: