Provider Demographics
NPI:1497276620
Name:CHRISTIAN, NICHOLAUS JAN
Entity Type:Individual
Prefix:
First Name:NICHOLAUS
Middle Name:JAN
Last Name:CHRISTIAN
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 1:1 LONG WHARF DR STE 321
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-5946
Mailing Address - Country:US
Mailing Address - Phone:203-781-4600
Mailing Address - Fax:203-781-4624
Practice Address - Street 1:1 LONG WHARF DR STE 321
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-5946
Practice Address - Country:US
Practice Address - Phone:203-781-4600
Practice Address - Fax:203-781-4624
Is Sole Proprietor?:No
Enumeration Date:2017-06-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10061302390200000X
CT68107207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004217099Medicaid
CT008102428Medicaid