Provider Demographics
NPI:1871961789
Name:VELLEMA, NICHOLAS
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:VELLEMA
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 1:4020 MERLE HAY RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50310-1310
Mailing Address - Country:US
Mailing Address - Phone:515-278-0949
Mailing Address - Fax:515-278-6721
Practice Address - Street 1:4020 MERLE HAY RD
Practice Address - Street 2:SUITE 100
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50310-1310
Practice Address - Country:US
Practice Address - Phone:515-278-0949
Practice Address - Fax:515-278-6721
Is Sole Proprietor?:No
Enumeration Date:2015-09-09
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA079188363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant