Provider Demographics
NPI:1295206134
Name:TIEU, NICHOLAS (PA-C)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:
Last Name:TIEU
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3233 COLONY HILL LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43204-2183
Mailing Address - Country:US
Mailing Address - Phone:847-508-2847
Mailing Address - Fax:
Practice Address - Street 1:415 6TH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2434
Practice Address - Country:US
Practice Address - Phone:208-743-2511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-17
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA1712363A00000X
OH50.005767RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty