Provider Demographics
NPI:1336143932
Name:NICHOLSON, STEPHEN FRANK (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:FRANK
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 1:36860 INDUSTRIAL WAY
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:OR
Mailing Address - Zip Code:97055-7371
Mailing Address - Country:US
Mailing Address - Phone:503-826-0206
Mailing Address - Fax:503-826-0216
Practice Address - Street 1:36860 INDUSTRIAL WAY
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:OR
Practice Address - Zip Code:97055-7371
Practice Address - Country:US
Practice Address - Phone:503-826-0206
Practice Address - Fax:503-826-0216
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD13735207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR284182Medicaid
C93405Medicare UPIN
OR284182Medicaid