Provider Demographics
NPI:1033562673
Name:NICHOLSON, SCOTT (PA)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:NICHOLSON
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 1:7477 E 46TH PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74145-6305
Mailing Address - Country:US
Mailing Address - Phone:918-384-0002
Mailing Address - Fax:918-384-0004
Practice Address - Street 1:1 S BRYANT AVE
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-6309
Practice Address - Country:US
Practice Address - Phone:405-341-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-19
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2676363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant