Basic Information
| Provider Information | |||||||||
| NPI: | 1023010162 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FERNANDO | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | EMILE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 917 WYNSTONE RD | ||||||||
| Address2: | |||||||||
| City: | JEFFERSON | ||||||||
| State: | SD | ||||||||
| PostalCode: | 570386875 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6054223102 | ||||||||
| FaxNumber: | 6054223103 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 TOWER RD | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | DAKOTA DUNES | ||||||||
| State: | SD | ||||||||
| PostalCode: | 570495007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6052177246 | ||||||||
| FaxNumber: | 6052174878 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2005 | ||||||||
| LastUpdateDate: | 12/07/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 0401 | SD | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.