Healthcare Provider Details

I. General information

NPI: 1922575737
Provider Name (Legal Business Name): NICHOLAS OLIVER BEREZICH NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2018
Last Update Date: 08/22/2024
Certification Date: 08/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 INDUSTRIAL AVE
AZLE TX
76020-2901
US

IV. Provider business mailing address

1301 N SAGINAW BLVD
SAGINAW TX
76179-5095
US

V. Phone/Fax

Practice location:
  • Phone: 817-444-3231
  • Fax:
Mailing address:
  • Phone: 817-847-6918
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP139345
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: