Provider Demographics
NPI:1376826925
Name:NICKELL, WILLIAM DAVID (PA-C)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:DAVID
Last Name:NICKELL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:DAVE
Other - Middle Name:
Other - Last Name:NICKELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:3533 SOUTHERN BLVD
Mailing Address - Street 2:SUITE 5650
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-1264
Mailing Address - Country:US
Mailing Address - Phone:937-294-3611
Mailing Address - Fax:937-294-9010
Practice Address - Street 1:3533 SOUTHERN BLVD STE 5650
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-1263
Practice Address - Country:US
Practice Address - Phone:937-294-3611
Practice Address - Fax:937-294-9010
Is Sole Proprietor?:No
Enumeration Date:2011-09-20
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH003357363A00000X, 363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0085670Medicaid
12286408OtherCIGNA/GREAT-WEST HEALTHCARE/SAGAMORE
OHH056820Medicare PIN
OH0085670Medicaid