Provider Demographics
NPI:1275603979
Name:NICHOLS, EWELL JR (CRNA)
Entity Type:Individual
Prefix:
First Name:EWELL
Middle Name:
Last Name:NICHOLS
Suffix:JR
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 UNION STREET
Mailing Address - Street 2:
Mailing Address - City:ELLSWORTH
Mailing Address - State:ME
Mailing Address - Zip Code:04605-1586
Mailing Address - Country:US
Mailing Address - Phone:207-664-5304
Mailing Address - Fax:207-664-5305
Practice Address - Street 1:50 UNION STREET
Practice Address - Street 2:
Practice Address - City:ELLSWORTH
Practice Address - State:ME
Practice Address - Zip Code:04605-1586
Practice Address - Country:US
Practice Address - Phone:207-664-5304
Practice Address - Fax:207-664-5305
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MER042011367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM856402Medicare PIN
MEMM8564Medicare PIN
MEJX1987Medicare PIN
MEMM856401Medicare PIN