Provider Demographics
NPI:1013069897
Name:MANSUETTA, NICHOLAS THOMAS (DO)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:THOMAS
Last Name:MANSUETTA
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 1:2810 W. 35TH ST
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68845-2909
Mailing Address - Country:US
Mailing Address - Phone:308-865-2570
Mailing Address - Fax:308-865-2508
Practice Address - Street 1:2810 W. 35TH ST
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68845-2909
Practice Address - Country:US
Practice Address - Phone:308-865-2570
Practice Address - Fax:308-865-2508
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE900207XS0106X, 207X00000X
ALDO575207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051558974OtherMEDICARE
051558974Medicare PIN
G85604Medicare UPIN