Provider Demographics
NPI:1316006109
Name:NICOLAS, RUTH (OD,PC)
Entity Type:Individual
Prefix:DR
First Name:RUTH
Middle Name:
Last Name:NICOLAS
Suffix:
Gender:F
Credentials:OD,PC
Other - Prefix:
Other - First Name:RUTH
Other - Middle Name:NICOLAS
Other - Last Name:BETHUNE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1867 AIRPORT WAY
Mailing Address - Street 2:SUITE 150-A
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-4007
Mailing Address - Country:US
Mailing Address - Phone:907-452-2131
Mailing Address - Fax:
Practice Address - Street 1:1867 AIRPORT WAY
Practice Address - Street 2:SUITE 150-A
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4007
Practice Address - Country:US
Practice Address - Phone:907-452-2131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAA125152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK0D01251Medicaid
AK0D01251Medicaid
T67065Medicare UPIN