Provider Demographics
NPI:1346217510
Name:NICHOLS, STEPHEN WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:WAYNE
Last Name:NICHOLS
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 1:3116 W. MARCH LN,
Mailing Address - Street 2:STE 200
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-2370
Mailing Address - Country:US
Mailing Address - Phone:209-473-6555
Mailing Address - Fax:209-473-6544
Practice Address - Street 1:1100 BUTTE ST
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-0852
Practice Address - Country:US
Practice Address - Phone:530-241-0410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA053775207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0055650Medicaid
CAA053775OtherLICENSE #
CABN4157473OtherDEA
CABN4157473OtherDEA
CAGR0055650Medicaid