Provider Demographics
NPI:1306010400
Name:NICKELL, SAMUEL AARON (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:AARON
Last Name:NICKELL
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 1:2400 TUCKER BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87131-0001
Mailing Address - Country:US
Mailing Address - Phone:505-272-2800
Mailing Address - Fax:
Practice Address - Street 1:4813 HAINES AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-5008
Practice Address - Country:US
Practice Address - Phone:505-508-2075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-18
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD 2012-04342084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry