Provider Demographics
NPI:1417525601
Name:NICKLE, MICHAEL TYSEN (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:TYSEN
Last Name:NICKLE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 LAKEVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-3597
Mailing Address - Country:US
Mailing Address - Phone:719-557-5872
Mailing Address - Fax:719-557-4780
Practice Address - Street 1:902 LAKEVIEW AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-3597
Practice Address - Country:US
Practice Address - Phone:719-557-5872
Practice Address - Fax:719-557-4780
Is Sole Proprietor?:No
Enumeration Date:2021-06-14
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COTL.0009001390200000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program