Provider Demographics
NPI:1104854728
Name:NICHOLAS, MERVYN BERTRAND (PA)
Entity Type:Individual
Prefix:MR
First Name:MERVYN
Middle Name:BERTRAND
Last Name:NICHOLAS
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:5505 BORDEAUX CT
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94591-6308
Mailing Address - Country:US
Mailing Address - Phone:707-980-0372
Mailing Address - Fax:925-372-2804
Practice Address - Street 1:5505 BORDEAUX CT
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94591-6308
Practice Address - Country:US
Practice Address - Phone:707-980-0372
Practice Address - Fax:925-372-2804
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPA15023363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical