Provider Demographics
NPI:1629441696
Name:ANZIDEO, NICHOLAS
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:ANZIDEO
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 1:657 WHITTIER DR
Mailing Address - Street 2:
Mailing Address - City:WARMINSTER
Mailing Address - State:PA
Mailing Address - Zip Code:18974-2059
Mailing Address - Country:US
Mailing Address - Phone:215-840-8118
Mailing Address - Fax:
Practice Address - Street 1:2099 NEW ALBANY RD
Practice Address - Street 2:
Practice Address - City:CINNAMINSON
Practice Address - State:NJ
Practice Address - Zip Code:08077-3534
Practice Address - Country:US
Practice Address - Phone:609-926-8899
Practice Address - Fax:856-772-1997
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-12
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA058011363AM0700X
PAOA003706363AM0700X
NJ25MP00518300363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical