Provider Demographics
NPI:1720033798
Name:DASOVICH, NICHOLES A (PA-C)
Entity Type:Individual
Prefix:
First Name:NICHOLES
Middle Name:A
Last Name:DASOVICH
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 1:142 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541-2922
Mailing Address - Country:US
Mailing Address - Phone:434-251-3318
Mailing Address - Fax:
Practice Address - Street 1:142 S MAIN ST
Practice Address - Street 2:EMERGENCY DEPT
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-2922
Practice Address - Country:US
Practice Address - Phone:434-799-2222
Practice Address - Fax:434-799-3857
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2010-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001598363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010187966Medicaid
P00276490Medicare ID - Type UnspecifiedRAILROAD GRP DA3179
VA008577D82Medicare ID - Type UnspecifiedGRP C08682
Q52076Medicare UPIN