Provider Demographics
NPI:1538129176
Name:NICHOLAS, STEPHANIE L (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:L
Last Name:NICHOLAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 OXFORD DR
Mailing Address - Street 2:SUITE 2C
Mailing Address - City:BETHEL PARK
Mailing Address - State:PA
Mailing Address - Zip Code:15102-1896
Mailing Address - Country:US
Mailing Address - Phone:412-854-3121
Mailing Address - Fax:
Practice Address - Street 1:1300 OXFORD DR
Practice Address - Street 2:SUITE 2C
Practice Address - City:BETHEL PARK
Practice Address - State:PA
Practice Address - Zip Code:15102-1896
Practice Address - Country:US
Practice Address - Phone:412-854-3121
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD045471L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1305124Medicaid
PAF40440Medicare UPIN
PA1305124Medicaid