Healthcare Provider Details

I. General information

NPI: 1700570298
Provider Name (Legal Business Name): NICOLAS STRONGE POUPORE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2023
Last Update Date: 06/23/2023
Certification Date: 06/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 RUTLEDGE AVE # MSC550
CHARLESTON SC
29425-8903
US

IV. Provider business mailing address

169 ASHLEY AVE RM 202
CHARLESTON SC
29425-8905
US

V. Phone/Fax

Practice location:
  • Phone: 843-876-0791
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberLL90258
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: