Provider Demographics
NPI:1114202108
Name:NICHOLS, KATHERINE M (PA)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:M
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:
Other - Last Name:RIVARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:33 LEWIS RD
Mailing Address - Street 2:2ND FL
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905
Mailing Address - Country:US
Mailing Address - Phone:607-770-0025
Mailing Address - Fax:607-729-3982
Practice Address - Street 1:33-57 HARRISON ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-2107
Practice Address - Country:US
Practice Address - Phone:607-763-5494
Practice Address - Fax:607-763-5116
Is Sole Proprietor?:No
Enumeration Date:2011-10-21
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015153363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant