Provider Demographics
NPI:1366764276
Name:BALOGA, NICHOLAS MARK (PA-C)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:MARK
Last Name:BALOGA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1932 ALCOA HWY
Mailing Address - Street 2:STE 360
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37920-1509
Mailing Address - Country:US
Mailing Address - Phone:865-524-1869
Mailing Address - Fax:865-544-6533
Practice Address - Street 1:1932 ALCOA HWY
Practice Address - Street 2:STE 360
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37920-1509
Practice Address - Country:US
Practice Address - Phone:865-524-1869
Practice Address - Fax:865-544-6533
Is Sole Proprietor?:No
Enumeration Date:2010-02-18
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1801363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1518131Medicaid
TN1518131Medicaid