Provider Demographics
NPI:1063480515
Name:NICHOLAS, ANGELA M (MD)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:M
Last Name:NICHOLAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:MARIE
Other - Last Name:HAAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 789967
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-9967
Mailing Address - Country:US
Mailing Address - Phone:484-622-7395
Mailing Address - Fax:484-622-7399
Practice Address - Street 1:212 N MAIN ST STE 203
Practice Address - Street 2:
Practice Address - City:NORTH WALES
Practice Address - State:PA
Practice Address - Zip Code:19454-3129
Practice Address - Country:US
Practice Address - Phone:215-699-1501
Practice Address - Fax:215-699-1505
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD056659L207Q00000X, 207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001480231Medicaid
PA447950OtherHIGHMARK BLUE SHIELD
PA1553630OtherUNITEDHEALTHCARE
PA5476555OtherAETNA
PAF96308OtherHEALTHAMERICA
PA447950OtherHIGHMARK BLUE SHIELD
F96308Medicare UPIN
PA080099800Medicare PIN