Basic Information
Provider Information | |||||||||
NPI: | 1669837381 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SUYDAM | ||||||||
FirstName: | NICHOLAS | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MS, PA-C, ATC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 560 S LOOP RD | ||||||||
Address2: |   | ||||||||
City: | EDGEWOOD | ||||||||
State: | KY | ||||||||
PostalCode: | 410173405 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8593012663 | ||||||||
FaxNumber: | 8598177848 | ||||||||
Practice Location | |||||||||
Address1: | 4355 FERGUSON DR | ||||||||
Address2: |   | ||||||||
City: | CINCINNATI | ||||||||
State: | OH | ||||||||
PostalCode: | 452455136 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5132322663 | ||||||||
FaxNumber: | 8598177848 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/22/2015 | ||||||||
LastUpdateDate: | 02/11/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/11/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X |   |   | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.