Provider Demographics
NPI:1083345607
Name:NICKELS, DAVID WILLIAM
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:WILLIAM
Last Name:NICKELS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8249 JUSTIN DR
Mailing Address - Street 2:
Mailing Address - City:CLAY
Mailing Address - State:NY
Mailing Address - Zip Code:13041-8979
Mailing Address - Country:US
Mailing Address - Phone:315-447-6461
Mailing Address - Fax:
Practice Address - Street 1:1419 SALT SPRINGS RD
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13214-1301
Practice Address - Country:US
Practice Address - Phone:315-445-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-23
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY030786363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program