Provider Demographics
NPI:1316037195
Name:NICHOLAS, CHRISTOPHER (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:NICHOLAS
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 1:1223 S GEAR AVE
Mailing Address - Street 2:SUITE #202
Mailing Address - City:WEST BURLINGTON
Mailing Address - State:IA
Mailing Address - Zip Code:52655-1682
Mailing Address - Country:US
Mailing Address - Phone:319-768-4350
Mailing Address - Fax:
Practice Address - Street 1:1223 S GEAR AVE
Practice Address - Street 2:SUITE #202
Practice Address - City:WEST BURLINGTON
Practice Address - State:IA
Practice Address - Zip Code:52655-1682
Practice Address - Country:US
Practice Address - Phone:319-768-4350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036112938208G00000X
IAMD34345208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036112938Medicaid
H57599Medicare UPIN
IL036112938Medicaid