Provider Demographics
NPI:1164412094
Name:NICHOLS, SHAWNN D (MD)
Entity Type:Individual
Prefix:
First Name:SHAWNN
Middle Name:D
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3551 ROGER BROOKE DR
Mailing Address - Street 2:
Mailing Address - City:FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-4504
Mailing Address - Country:US
Mailing Address - Phone:210-916-3334
Mailing Address - Fax:210-916-2202
Practice Address - Street 1:3551 ROGER BROOKE DR
Practice Address - Street 2:POC MS SYLVIA LISERIO
Practice Address - City:FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-4504
Practice Address - Country:US
Practice Address - Phone:210-916-3334
Practice Address - Fax:210-916-2202
Is Sole Proprietor?:No
Enumeration Date:2005-10-22
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36084412208600000X
OH35.0844142086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
No208600000XAllopathic & Osteopathic PhysiciansSurgery