Provider Demographics
NPI:1922887553
Name:GOLDSACK, NICHOLAS JAMES
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:JAMES
Last Name:GOLDSACK
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 1:716 STEVENS AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-2693
Mailing Address - Country:US
Mailing Address - Phone:207-283-0171
Mailing Address - Fax:
Practice Address - Street 1:33 FERRY ST
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:NH
Practice Address - Zip Code:03051-4215
Practice Address - Country:US
Practice Address - Phone:603-759-2251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty