Provider Demographics
NPI:1356051098
Name:CRODICK, NICHOLAS JAMES (PA)
Entity type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:JAMES
Last Name:CRODICK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:NICHOLAS
Other - Middle Name:J
Other - Last Name:CRODICK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:600 GRESHAM DR STE 8600
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-1904
Mailing Address - Country:US
Mailing Address - Phone:757-388-6005
Mailing Address - Fax:
Practice Address - Street 1:600 GRESHAM DR STE 8600
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1904
Practice Address - Country:US
Practice Address - Phone:757-388-6005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-05
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0110009381363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program