Provider Demographics
NPI:1649842766
Name:BATHURST, NICHOLAS A
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:A
Last Name:BATHURST
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 1:1604 VISA DR STE 1
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-2195
Mailing Address - Country:US
Mailing Address - Phone:309-846-4716
Mailing Address - Fax:309-454-7348
Practice Address - Street 1:CARLE BROMENN MEDICAL CENTER
Practice Address - Street 2:1304 FRANKLIN AVE.
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761
Practice Address - Country:US
Practice Address - Phone:309-454-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-16
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic