Provider Demographics
NPI:1932718152
Name:NIX, STEPHEN WALTER
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:WALTER
Last Name:NIX
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 1:12767 91ST AVE N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-6511
Mailing Address - Country:US
Mailing Address - Phone:612-382-3845
Mailing Address - Fax:
Practice Address - Street 1:12767 91ST AVE N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-6511
Practice Address - Country:US
Practice Address - Phone:612-382-3845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-23
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347E00000XTransportation ServicesTransportation Broker