Provider Demographics
NPI:1326014820
Name:NICKS, ANDREW J (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:J
Last Name:NICKS
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 348120
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95834
Mailing Address - Country:US
Mailing Address - Phone:707-252-4633
Mailing Address - Fax:707-252-2240
Practice Address - Street 1:1000 TRANCAS STREET
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-2906
Practice Address - Country:US
Practice Address - Phone:707-252-4411
Practice Address - Fax:707-252-2240
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG247152085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G247150Medicaid
CA00G247150Medicaid
CA010050533Medicare PIN
CAA42352Medicare UPIN
CA00G247151Medicare PIN