Provider Demographics
NPI:1003877937
Name:NICHOLSON, TANYA G (OD)
Entity Type:Individual
Prefix:DR
First Name:TANYA
Middle Name:G
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:396 N SNOWMASS CIR
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:CO
Mailing Address - Zip Code:80027-6124
Mailing Address - Country:US
Mailing Address - Phone:303-818-1852
Mailing Address - Fax:
Practice Address - Street 1:1250 E MAGNOLIA ST
Practice Address - Street 2:LOCATED IN WAL-MART
Practice Address - City:FT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-2754
Practice Address - Country:US
Practice Address - Phone:970-224-0606
Practice Address - Fax:970-493-9309
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2094152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COU87557Medicare UPIN
CO804579Medicare ID - Type Unspecified