Provider Demographics
NPI:1710617071
Name:PROSPER, NICHOLAS (PA-C)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:PROSPER
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 1:516 JENNA DR
Mailing Address - Street 2:
Mailing Address - City:BRODHEADSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18322-7141
Mailing Address - Country:US
Mailing Address - Phone:272-212-4000
Mailing Address - Fax:
Practice Address - Street 1:100 ST LUKES LN
Practice Address - Street 2:
Practice Address - City:STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18360-6217
Practice Address - Country:US
Practice Address - Phone:866-785-8537
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-10
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant