Provider Demographics
NPI:1922762756
Name:SANDUSKY, NICHOLAS PAUL
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:PAUL
Last Name:SANDUSKY
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 1:3200 SAINT ROSE RD
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:KY
Mailing Address - Zip Code:40033-9132
Mailing Address - Country:US
Mailing Address - Phone:270-692-8969
Mailing Address - Fax:
Practice Address - Street 1:789 SOUTH LIMESTONE STREET
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-0001
Practice Address - Country:US
Practice Address - Phone:270-692-8969
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-27
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYI14910390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program