Provider Demographics
NPI:1205428893
Name:HAGANDORA, NICHOLAS (FNP)
Entity type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:
Last Name:HAGANDORA
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 SINGLETON RIDGE ROAD
Mailing Address - Street 2:ATTENTION PATIENT ACCOUNTING
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-9142
Mailing Address - Country:US
Mailing Address - Phone:843-234-6946
Mailing Address - Fax:
Practice Address - Street 1:2376 CYPRESS CIR STE 102
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-8964
Practice Address - Country:US
Practice Address - Phone:843-347-8953
Practice Address - Fax:843-347-0226
Is Sole Proprietor?:No
Enumeration Date:2021-02-05
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC24654363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily