Provider Demographics
NPI:1275563637
Name:NICHOLAS, MICHAEL ERNEST JR (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ERNEST
Last Name:NICHOLAS
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2805 N. DALLAS PKWY
Mailing Address - Street 2:SUITE 640
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-8724
Mailing Address - Country:US
Mailing Address - Phone:214-277-3404
Mailing Address - Fax:
Practice Address - Street 1:3014 N. O CONNOR
Practice Address - Street 2:SUITE 110
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75062-4415
Practice Address - Country:US
Practice Address - Phone:214-277-3404
Practice Address - Fax:817-488-4493
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04164363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA04164OtherLICENSE