Provider Demographics
NPI:1013510767
Name:LORD, NICHOLAS H
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:H
Last Name:LORD
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 1:512 E GIRARD AVE APT 202
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19125-3358
Mailing Address - Country:US
Mailing Address - Phone:570-573-4869
Mailing Address - Fax:
Practice Address - Street 1:512 E GIRARD AVE APT 202
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19125-3358
Practice Address - Country:US
Practice Address - Phone:570-573-4869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-17
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00611400363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant