Provider Demographics
NPI:1265618722
Name:HAMMOND, NICHOLAS J (PA)
Entity type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:J
Last Name:HAMMOND
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 W BERRY ST
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46802-2106
Mailing Address - Country:US
Mailing Address - Phone:260-423-1331
Mailing Address - Fax:
Practice Address - Street 1:604 W BERRY ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46802-2106
Practice Address - Country:US
Practice Address - Phone:260-423-1331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-15
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000887A363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN10000887AOtherIN LICENSE