Healthcare Provider Details

I. General information

NPI: 1790095933
Provider Name (Legal Business Name): JOHN DAVID NICHOLSON JR. PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2010
Last Update Date: 10/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 N 49TH ST
PHILADELPHIA PA
19139-2718
US

IV. Provider business mailing address

111 N 49TH ST
PHILADELPHIA PA
19139-2718
US

V. Phone/Fax

Practice location:
  • Phone: 215-471-2488
  • Fax: 215-471-2897
Mailing address:
  • Phone: 215-471-2488
  • Fax: 215-471-2897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA001440L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: