Healthcare Provider Details

I. General information

NPI: 1720430853
Provider Name (Legal Business Name): NICHOLAS CROMIDAS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2016
Last Update Date: 07/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1920 NE TERRE VIEW DR APT. I203
PULLMAN WA
99163-4591
US

IV. Provider business mailing address

1920 NE TERRE VIEW DR APT. I203
PULLMAN WA
99163-4591
US

V. Phone/Fax

Practice location:
  • Phone: 661-713-0996
  • Fax:
Mailing address:
  • Phone: 661-713-0996
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: