Provider Demographics
NPI:1518160340
Name:NICGORSKI, KEVIN M (CRNA)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:NICGORSKI
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1245 S CEDAR CREST BLVD STE 301
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-6258
Mailing Address - Country:US
Mailing Address - Phone:610-402-9099
Mailing Address - Fax:610-402-9029
Practice Address - Street 1:1200 S CEDAR CREST BLVD
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-6202
Practice Address - Country:US
Practice Address - Phone:610-402-9099
Practice Address - Fax:610-402-9029
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN-352827-L163W00000X
PA075697367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA11803063OtherCAQH
PA50069827OtherCAPITAL ADVANTAGE
PA1580477OtherGATEWAY
PA1978853OtherHIGHMARK
PA9077443OtherAETNA
PA1978853OtherFIRST PRIORITY
PA2031873000OtherIBC
PA108433OtherGEISINGER
PA1027794950001Medicaid
PA1027794950001Medicaid
PA114586QCYMedicare PIN