Provider Demographics
NPI:1821091455
Name:NOURSE, TRENT H (PA-C, MPAS)
Entity Type:Individual
Prefix:
First Name:TRENT
Middle Name:H
Last Name:NOURSE
Suffix:
Gender:M
Credentials:PA-C, MPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7774 DAYTON SPRINGFIELD RD
Mailing Address - Street 2:
Mailing Address - City:FAIRBORN
Mailing Address - State:OH
Mailing Address - Zip Code:45324-1957
Mailing Address - Country:US
Mailing Address - Phone:937-864-7363
Mailing Address - Fax:937-864-5895
Practice Address - Street 1:7774 DAYTON SPRINGFIELD RD
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-1957
Practice Address - Country:US
Practice Address - Phone:937-864-7363
Practice Address - Fax:937-864-5895
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH-50-00-1406207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHNOPA17541Medicare ID - Type Unspecified
OHP35978Medicare UPIN