Provider Demographics
NPI:1285628180
Name:OSWALD, NICCOLE M (MD)
Entity Type:Individual
Prefix:
First Name:NICCOLE
Middle Name:M
Last Name:OSWALD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NICCOLE
Other - Middle Name:M
Other - Last Name:MAMBU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 420
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18962-0420
Mailing Address - Country:US
Mailing Address - Phone:215-258-3810
Mailing Address - Fax:215-258-3815
Practice Address - Street 1:164 MAIN ST
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:PA
Practice Address - Zip Code:18962
Practice Address - Country:US
Practice Address - Phone:215-258-3810
Practice Address - Fax:215-258-3815
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD418021207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001749964OtherHIGHMARK BCBS
H63885Medicare UPIN
PA001749964OtherHIGHMARK BCBS