Provider Demographics
NPI:1043850787
Name:MORREALE, NICHOLAS
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:MORREALE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 BEAR CREEK RD
Mailing Address - Street 2:
Mailing Address - City:DUPONT
Mailing Address - State:PA
Mailing Address - Zip Code:18641-1933
Mailing Address - Country:US
Mailing Address - Phone:570-212-1176
Mailing Address - Fax:
Practice Address - Street 1:1000 E MOUNTAIN BLVD
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18711-0027
Practice Address - Country:US
Practice Address - Phone:570-808-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-10
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN650613367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARN650613OtherRN LICENSE