Provider Demographics
NPI:1205428042
Name:HEARST, NICHOLAS (LMT)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:HEARST
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4909 MARKET ST APT 2
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19139-3665
Mailing Address - Country:US
Mailing Address - Phone:215-433-5268
Mailing Address - Fax:
Practice Address - Street 1:970 PULASKI DR
Practice Address - Street 2:
Practice Address - City:KING OF PRUSSIA
Practice Address - State:PA
Practice Address - Zip Code:19406-2802
Practice Address - Country:US
Practice Address - Phone:610-640-9355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-03
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG012206225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist