Provider Demographics
NPI:1932568391
Name:TENNEY, NICHOLAS A
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:A
Last Name:TENNEY
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:PO BOX 570892
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89157-0892
Mailing Address - Country:US
Mailing Address - Phone:323-487-1652
Mailing Address - Fax:
Practice Address - Street 1:3433 ALGIERS DR APT 2192
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89115-2848
Practice Address - Country:US
Practice Address - Phone:702-823-6207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-15
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171363246ZS0410X
246ZC0007X
171363246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
171363OtherNBSTSA