Basic Information
| Provider Information | |||||||||
| NPI: | 1073077715 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NILES | ||||||||
| FirstName: | TODD | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 SEAGATE # 800 | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436041558 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5300 HARROUN RD STE 304 | ||||||||
| Address2: | |||||||||
| City: | SYLVANIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435602146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198241100 | ||||||||
| FaxNumber: | 4198241778 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2019 | ||||||||
| LastUpdateDate: | 03/11/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 4704223808 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | RN251795 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | APRN.CNP.024070 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.