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NPI Code Detail

MEDICARE: NATHAN D. NICOLA NP

MEDICARE: NATHAN D. NICOLA NP
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363LF0000XFamily Nurse Practitioner71009821AIN

General Provider Information

NPI Number : 1154956209
Entity Type Code : Individual
Provider Name (Legal Business Name) : NATHAN D. NICOLA NP
Provider Business Mailing Address
First Line : 6920 POINTE INVERNESS WAY STE 200
Second Line :
City : FORT WAYNE
State : IN
Zip : 46804-7934
Country : US
Telephone Number : 260-479-3516
Fax Number : 260-479-3520
Provider Business Practice Location Address
First Line : 6511 E STATE BLVD
Second Line :
City : FORT WAYNE
State : IN
Zip : 46815-7026
Country : US
Telephone Number : 260-425-2725
Fax Number : 260-479-4604
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/10/2020
Last Update Date : 10/15/2020

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