Healthcare Provider Details

I. General information

NPI: 1881276244
Provider Name (Legal Business Name): NICHOLAS PAUL CUNNINGHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2021
Last Update Date: 09/02/2021
Certification Date: 09/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 S MAIN ST
DU BOIS PA
15801-1413
US

IV. Provider business mailing address

100 HOSPITAL AVE
DU BOIS PA
15801-1440
US

V. Phone/Fax

Practice location:
  • Phone: 814-299-7520
  • Fax: 814-375-7798
Mailing address:
  • Phone: 814-375-4024
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA062583
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: