Healthcare Provider Details

I. General information

NPI: 1821387622
Provider Name (Legal Business Name): NICHOLAS DALESSANDRO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2011
Last Update Date: 05/24/2021
Certification Date: 04/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 W LANCASTER AVE
PAOLI PA
19301-1763
US

IV. Provider business mailing address

255 W LANCASTER AVE
PAOLI PA
19301-1763
US

V. Phone/Fax

Practice location:
  • Phone: 484-565-1510
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOS017091
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: