Provider Demographics
NPI:1326685991
Name:LINCAVAGE, NIKOLAI X (CST, SA-C)
Entity Type:Individual
Prefix:
First Name:NIKOLAI
Middle Name:X
Last Name:LINCAVAGE
Suffix:
Gender:M
Credentials:CST, SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29277 US HIGHWAY 19 N # 29277
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33761-2102
Mailing Address - Country:US
Mailing Address - Phone:727-313-4764
Mailing Address - Fax:
Practice Address - Street 1:29277 US HIGHWAY 19 N # 29277
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33761-2102
Practice Address - Country:US
Practice Address - Phone:727-313-4764
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-03
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246ZS0410X
19-469363AS0400X, 246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
19-469OtherABSA