Provider Demographics
NPI:1073614236
Name:NICELY, JAMES H (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:H
Last Name:NICELY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
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Mailing Address - Street 1:1001 MOUNTAIN ST
Mailing Address - Street 2:SUITE 3 M
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89703-3822
Mailing Address - Country:US
Mailing Address - Phone:775-885-8890
Mailing Address - Fax:775-885-8865
Practice Address - Street 1:1001 MOUNTAIN ST
Practice Address - Street 2:SUITE 3 M
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89703-3822
Practice Address - Country:US
Practice Address - Phone:775-885-8890
Practice Address - Fax:775-885-8865
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NV123363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002413010Medicaid
NVPA123BMedicare ID - Type Unspecified
NV002413010Medicaid
NV38689Medicare ID - Type Unspecified