Healthcare Provider Details

I. General information

NPI: 1720761513
Provider Name (Legal Business Name): ERICK NAZARENO PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2023
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 S STANFIELD RD STE A
TROY OH
45373-2569
US

IV. Provider business mailing address

1 PRESTIGE PL STE 550
MIAMISBURG OH
45342-6115
US

V. Phone/Fax

Practice location:
  • Phone: 937-339-5355
  • Fax: 937-339-3056
Mailing address:
  • Phone: 937-762-1306
  • Fax: 937-522-7017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.008396RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: