Provider Demographics
NPI:1457404816
Name:MONACO, NICHOLAS
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:MONACO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 SANTANA ROW APT 237
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-2008
Mailing Address - Country:US
Mailing Address - Phone:415-745-5665
Mailing Address - Fax:408-516-9377
Practice Address - Street 1:105 N BASCOM AVE STE 202
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-1811
Practice Address - Country:US
Practice Address - Phone:415-745-5665
Practice Address - Fax:408-516-9377
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54966207RN0300X
ART2006-186207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR164697001Medicaid
AR5N7677498Medicare PIN
ARG96333Medicare UPIN