Provider Demographics
NPI:1750845376
Name:SNYDER, NICHOLAS A
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:A
Last Name:SNYDER
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 1:205 E EMILY ST
Mailing Address - Street 2:
Mailing Address - City:FREEBURG
Mailing Address - State:IL
Mailing Address - Zip Code:62243-1509
Mailing Address - Country:US
Mailing Address - Phone:618-402-6518
Mailing Address - Fax:
Practice Address - Street 1:4970 OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1402
Practice Address - Country:US
Practice Address - Phone:618-402-6518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-28
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20210432492255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer