Provider Demographics
NPI:1013691153
Name:SOUTHERTON, NICHOLAS MOORE (CNP)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:MOORE
Last Name:SOUTHERTON
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2124 144TH LN NE
Mailing Address - Street 2:
Mailing Address - City:HAM LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55304-6260
Mailing Address - Country:US
Mailing Address - Phone:763-248-4011
Mailing Address - Fax:
Practice Address - Street 1:1415 LILAC DR N
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55422-4500
Practice Address - Country:US
Practice Address - Phone:763-205-4168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-09
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10301363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology