Provider Demographics
NPI:1518627314
Name:NICHOLAS, AJ DUANE
Entity Type:Individual
Prefix:
First Name:AJ
Middle Name:DUANE
Last Name:NICHOLAS
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 1:47311 SILVER SLATE DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20653-2448
Mailing Address - Country:US
Mailing Address - Phone:772-713-9786
Mailing Address - Fax:
Practice Address - Street 1:47149 BUSE RD BLDG 1370
Practice Address - Street 2:
Practice Address - City:PATUXENT RIVER
Practice Address - State:MD
Practice Address - Zip Code:20670-1540
Practice Address - Country:US
Practice Address - Phone:301-342-1499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-21
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician