Provider Demographics
NPI:1114457991
Name:CAMILLERI, NICHOLAS ANTHONY
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:ANTHONY
Last Name:CAMILLERI
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 1:2006 HOGBACK RD STE 5A
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-9750
Mailing Address - Country:US
Mailing Address - Phone:734-786-2317
Mailing Address - Fax:734-786-4977
Practice Address - Street 1:205 NORTH EAST AVENUE
Practice Address - Street 2:ANESTHESIA DEPARTMENT
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201
Practice Address - Country:US
Practice Address - Phone:517-788-4963
Practice Address - Fax:517-789-5903
Is Sole Proprietor?:No
Enumeration Date:2017-06-14
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704272138367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered