Provider Demographics
NPI:1811384704
Name:STULL, NICHOLAS WADE (DO)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:WADE
Last Name:STULL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3421 W 9TH ST
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50702-5401
Mailing Address - Country:US
Mailing Address - Phone:231-313-1702
Mailing Address - Fax:
Practice Address - Street 1:3421 W 9TH ST
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50702-5401
Practice Address - Country:US
Practice Address - Phone:319-272-8000
Practice Address - Fax:319-272-7313
Is Sole Proprietor?:No
Enumeration Date:2015-04-19
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101021742207P00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5315070508OtherCONTROLLED SUBSTANCE LICENSE