Provider Demographics
NPI:1467424754
Name:JOSEPH, NICKIE (DPM)
Entity Type:Individual
Prefix:
First Name:NICKIE
Middle Name:
Last Name:JOSEPH
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2111 WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:PA
Mailing Address - Zip Code:18042-3803
Mailing Address - Country:US
Mailing Address - Phone:610-253-9617
Mailing Address - Fax:610-253-6705
Practice Address - Street 1:2111 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:PA
Practice Address - Zip Code:18042-3803
Practice Address - Country:US
Practice Address - Phone:610-253-9617
Practice Address - Fax:610-253-6705
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC005889213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1014105520001Medicaid
V07775Medicare UPIN
PA096899LPBMedicare PIN