Healthcare Provider Details

I. General information

NPI: 1629441696
Provider Name (Legal Business Name): NICHOLAS ANZIDEO PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2015
Last Update Date: 04/14/2025
Certification Date: 04/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 HORSHAM RD STE 201
NORTH WALES PA
19454-1500
US

IV. Provider business mailing address

657 WHITTIER DR
WARMINSTER PA
18974-2059
US

V. Phone/Fax

Practice location:
  • Phone: 215-362-2385
  • Fax: 215-361-1584
Mailing address:
  • Phone: 215-840-8118
  • 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 Code363AM0700X
TaxonomyMedical Physician Assistant
License Number25MP00518300
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA058011
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberOA003706
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: