Provider Demographics
NPI:1043612070
Name:THIBAULT, NICHOLAS JOHN (PA-C)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:JOHN
Last Name:THIBAULT
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 1:1900 GATOR BLVD
Mailing Address - Street 2:BUILDING 3808
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23459-8950
Mailing Address - Country:US
Mailing Address - Phone:757-763-3619
Mailing Address - Fax:
Practice Address - Street 1:1003 CHURCHILL WAY APT 2E
Practice Address - Street 2:
Practice Address - City:MIDWAY PARK
Practice Address - State:NC
Practice Address - Zip Code:28544-1285
Practice Address - Country:US
Practice Address - Phone:219-689-8493
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-22
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical