Provider Demographics
NPI:1578165379
Name:FOX, NICHOLAS R (PA-C)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:R
Last Name:FOX
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 W NORTH DOWN RIVER RD
Mailing Address - Street 2:
Mailing Address - City:GRAYLING
Mailing Address - State:MI
Mailing Address - Zip Code:49738-2060
Mailing Address - Country:US
Mailing Address - Phone:989-348-0800
Mailing Address - Fax:
Practice Address - Street 1:1010 W NORTH DOWN RIVER RD
Practice Address - Street 2:
Practice Address - City:GRAYLING
Practice Address - State:MI
Practice Address - Zip Code:49738-2060
Practice Address - Country:US
Practice Address - Phone:989-348-0800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-16
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601010230363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty