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Individual
DR. NICHOLAS S BOGANNAM
Active
Individual
DR. NICHOLAS S BOGANNAM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.C.
Taxonomy
Speciality
Code
Description
License number
State
111N00000X
Chiropractor
Primary
253CT01
CT
111NN1001X
Nutrition Chiropractor
253CT01
CT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
06-1066319
TAX ID #
CT
01
—
253CT01
STATE LICENSE NUMBER
CT
Enumeration date
12/06/2006
Last updated
09/08/2010
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