Provider Demographics
NPI:1073288767
Name:NICHOLES, MARC (DO)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:
Last Name:NICHOLES
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18511 HIGHLANDER MEDICS STREET
Mailing Address - Street 2:
Mailing Address - City:FT. BLISS
Mailing Address - State:TX
Mailing Address - Zip Code:79918
Mailing Address - Country:US
Mailing Address - Phone:915-742-0576
Mailing Address - Fax:
Practice Address - Street 1:18511 HIGHLANDER MEDICS STREET
Practice Address - Street 2:
Practice Address - City:FT. BLISS
Practice Address - State:TX
Practice Address - Zip Code:79918
Practice Address - Country:US
Practice Address - Phone:915-742-0576
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-13
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10081686390200000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program