Provider Demographics
NPI:1861152589
Name:ANDERJACK, NICHOLAS JOHN (PA-C)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:JOHN
Last Name:ANDERJACK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 GREENLAWN DR
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15220-3103
Mailing Address - Country:US
Mailing Address - Phone:412-443-7405
Mailing Address - Fax:
Practice Address - Street 1:1160 CHILI AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14624-3035
Practice Address - Country:US
Practice Address - Phone:585-426-4990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-21
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA062858363A00000X
PAOA005933363A00000X
NY027653-01363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant