Provider Demographics
NPI:1164886230
Name:DEETER, NICHOLAS BARRY (DO)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:BARRY
Last Name:DEETER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 W COMMERCE DR # 2093
Mailing Address - Street 2:
Mailing Address - City:BELLE PLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:56011-2911
Mailing Address - Country:US
Mailing Address - Phone:952-777-5661
Mailing Address - Fax:
Practice Address - Street 1:165 W COMMERCE DR # 2093
Practice Address - Street 2:
Practice Address - City:BELLE PLAINE
Practice Address - State:MN
Practice Address - Zip Code:56011-2911
Practice Address - Country:US
Practice Address - Phone:952-777-5661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-05
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI68241-21207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine