Healthcare Provider Details

I. General information

NPI: 1083292585
Provider Name (Legal Business Name): JON DEREK NICASSIO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2021
Last Update Date: 02/13/2025
Certification Date: 02/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8791 BARNES LAKE RD STE 101
NORTH HUNTINGDON PA
15642-3176
US

IV. Provider business mailing address

8791 BARNES LAKE RD STE 101
NORTH HUNTINGDON PA
15642-3176
US

V. Phone/Fax

Practice location:
  • Phone: 724-864-9400
  • Fax: 724-864-8044
Mailing address:
  • Phone: 724-864-9400
  • Fax: 724-864-8044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS023552
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: