Provider Demographics
NPI:1689098931
Name:BOGUSLAW, NICHOLLE (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:NICHOLLE
Middle Name:
Last Name:BOGUSLAW
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 JADE AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17821-8536
Mailing Address - Country:US
Mailing Address - Phone:570-594-9834
Mailing Address - Fax:
Practice Address - Street 1:1 KELLEY DR
Practice Address - Street 2:
Practice Address - City:COAL TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:17866-1020
Practice Address - Country:US
Practice Address - Phone:570-644-7890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-06
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA055934363A00000X
PAOA002976363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant