Provider Demographics
NPI:1629433024
Name:PEDDICORD, ADAM NICHOLAS (APRN)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:NICHOLAS
Last Name:PEDDICORD
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 ELSINORE PL STE 200
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45202-1457
Mailing Address - Country:US
Mailing Address - Phone:513-834-7063
Mailing Address - Fax:
Practice Address - Street 1:4135 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:ELSMERE
Practice Address - State:KY
Practice Address - Zip Code:41018-1815
Practice Address - Country:US
Practice Address - Phone:513-834-7063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-30
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3009900363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK145940Medicare PIN