Provider Demographics
NPI:1306856752
Name:NICHOLS, JOHN STEPHAN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:STEPHAN
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:
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 6210
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87499-6210
Mailing Address - Country:US
Mailing Address - Phone:505-609-2258
Mailing Address - Fax:505-609-2259
Practice Address - Street 1:11750 W 2ND PL
Practice Address - Street 2:SUITE 255
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80228-1575
Practice Address - Country:US
Practice Address - Phone:720-321-8040
Practice Address - Fax:720-321-8041
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO26919207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01269190Medicaid
CO01269190Medicaid
COC366648Medicare PIN