Provider Demographics
NPI:1023010162
Name:FERNANDO, NICHOLAS EMILE (PA-C)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:EMILE
Last Name:FERNANDO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:917 WYNSTONE RD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:SD
Mailing Address - Zip Code:57038-6875
Mailing Address - Country:US
Mailing Address - Phone:605-422-3102
Mailing Address - Fax:605-422-3103
Practice Address - Street 1:101 TOWER RD
Practice Address - Street 2:SUITE 103
Practice Address - City:DAKOTA DUNES
Practice Address - State:SD
Practice Address - Zip Code:57049-5007
Practice Address - Country:US
Practice Address - Phone:605-217-7246
Practice Address - Fax:605-217-4878
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2017-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0401363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6039Medicare ID - Type Unspecified
S64517Medicare UPIN
IAI0524006Medicare PIN
IA47952Medicare ID - Type Unspecified