Provider Demographics
NPI:1467701425
Name:WILEY, NICHOLAS ALAN
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:ALAN
Last Name:WILEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1038 MEADOW REACH TRL
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27332-8333
Mailing Address - Country:US
Mailing Address - Phone:816-588-8596
Mailing Address - Fax:
Practice Address - Street 1:1038 MEADOW REACH TRL
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27332-8333
Practice Address - Country:US
Practice Address - Phone:816-588-8596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-06
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman