Provider Demographics
NPI:1255603510
Name:MYCHAK, NATHAN (PA-C)
Entity type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:
Last Name:MYCHAK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:157 BALTIMORE ST
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-2472
Mailing Address - Country:US
Mailing Address - Phone:301-722-3215
Mailing Address - Fax:
Practice Address - Street 1:157 BALTIMORE ST STE 100
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-2472
Practice Address - Country:US
Practice Address - Phone:301-722-0484
Practice Address - Fax:833-903-0130
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-02
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0004713363A00000X
OK2552363A00000X
PA057046363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant