Provider Demographics
NPI:1164298543
Name:SUPERKO, NICHOLAS ALAN
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:ALAN
Last Name:SUPERKO
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 1:241 DOOLITTLE HILL RD
Mailing Address - Street 2:
Mailing Address - City:LACEYVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18623-6637
Mailing Address - Country:US
Mailing Address - Phone:570-721-5209
Mailing Address - Fax:
Practice Address - Street 1:148 ENNIS LN
Practice Address - Street 2:
Practice Address - City:TOWANDA
Practice Address - State:PA
Practice Address - Zip Code:18848-9198
Practice Address - Country:US
Practice Address - Phone:570-265-4769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-28
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPI124458390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program