Provider Demographics
NPI:1306853742
Name:NICHOLSON, CRAIG RAYMOND (MD)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:RAYMOND
Last Name:NICHOLSON
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:PO BOX 249
Mailing Address - Street 2:
Mailing Address - City:FORT BENTON
Mailing Address - State:MT
Mailing Address - Zip Code:59442-0249
Mailing Address - Country:US
Mailing Address - Phone:406-622-5485
Mailing Address - Fax:406-622-3882
Practice Address - Street 1:1203 15TH ST
Practice Address - Street 2:
Practice Address - City:FORT BENTON
Practice Address - State:MT
Practice Address - Zip Code:59442
Practice Address - Country:US
Practice Address - Phone:406-622-5485
Practice Address - Fax:406-622-3882
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT4689207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0153166Medicaid
MTD07948Medicare UPIN