Provider Demographics
NPI:1073543757
Name:HARDIN, NICHOLAS JACKSON (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:JACKSON
Last Name:HARDIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 TREE HILL RD
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-9041
Mailing Address - Country:US
Mailing Address - Phone:802-878-8458
Mailing Address - Fax:
Practice Address - Street 1:111 COLCHESTER AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-1473
Practice Address - Country:US
Practice Address - Phone:802-847-2795
Practice Address - Fax:802-847-9644
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0005931207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT00048301Medicaid
NY00787444Medicaid
VTC65339Medicare UPIN
VT00048301Medicaid