Provider Demographics
NPI:1427565068
Name:NICODEMUS, WILLIAM ALEX (FNP-C)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:ALEX
Last Name:NICODEMUS
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3120 VAN ZANT COUNTY ROAD 2318
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:TX
Mailing Address - Zip Code:75103
Mailing Address - Country:US
Mailing Address - Phone:903-479-3933
Mailing Address - Fax:903-479-9333
Practice Address - Street 1:2900 S LOOP 256
Practice Address - Street 2:
Practice Address - City:PALESTINE
Practice Address - State:TX
Practice Address - Zip Code:75801-6958
Practice Address - Country:US
Practice Address - Phone:903-731-1134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-04
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP135915363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily