Healthcare Provider Details

I. General information

NPI: 1407489032
Provider Name (Legal Business Name): NICHOLAS MANKOWSKI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2020
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3822 MAYFAIR ST
MYRTLE BEACH SC
29577-0912
US

IV. Provider business mailing address

3822 MAYFAIR ST
MYRTLE BEACH SC
29577-0912
US

V. Phone/Fax

Practice location:
  • Phone: 843-449-6449
  • Fax: 843-449-1069
Mailing address:
  • Phone: 843-449-6449
  • Fax: 843-449-1069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberMD96557
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: