Provider Demographics
NPI:1417024563
Name:NICKERSON, KATHERINE GRACE (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:GRACE
Last Name:NICKERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:161 FT WASHINGTN AVE
Mailing Address - Street 2:ROOM 218
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3729
Mailing Address - Country:US
Mailing Address - Phone:212-305-4308
Mailing Address - Fax:212-304-6610
Practice Address - Street 1:161 FT WASHINGTN AVE
Practice Address - Street 2:ROOM 218
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3729
Practice Address - Country:US
Practice Address - Phone:212-305-4308
Practice Address - Fax:212-304-6610
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2014-10-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY157790207R00000X, 207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01021407Medicaid
NY01021407Medicaid
NY96D031Medicare ID - Type Unspecified