Provider Demographics
NPI:1679025373
Name:CALVIN, NICHOLAS M (PA-C)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:M
Last Name:CALVIN
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 1:700 ACKERMAN RD
Mailing Address - Street 2:SUITE 570
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1559
Mailing Address - Country:US
Mailing Address - Phone:614-293-8566
Mailing Address - Fax:614-293-9024
Practice Address - Street 1:915 OLENTANGY RIVER RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43212-3153
Practice Address - Country:US
Practice Address - Phone:614-293-8566
Practice Address - Fax:614-293-3381
Is Sole Proprietor?:No
Enumeration Date:2016-10-28
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.004916RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0201757Medicaid
OHH422130Medicare PIN