Provider Demographics
NPI:1073690236
Name:NICKELL, JON B (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JON
Middle Name:B
Last Name:NICKELL
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1214 HILLTOP CIR
Mailing Address - Street 2:
Mailing Address - City:NORTH PLATTE
Mailing Address - State:NE
Mailing Address - Zip Code:69101-6734
Mailing Address - Country:US
Mailing Address - Phone:308-532-8789
Mailing Address - Fax:
Practice Address - Street 1:2 W 42ND ST
Practice Address - Street 2:SUITE 1500
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-4669
Practice Address - Country:US
Practice Address - Phone:308-635-7362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE100127367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE272134NIMedicare ID - Type UnspecifiedORIGINAL ASSIGNED CRNA