Provider Demographics
NPI:1437140357
Name:NICHOLS, GARY DALE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:DALE
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:191 PRIVATE ROAD 845
Mailing Address - Street 2:
Mailing Address - City:TEAGUE
Mailing Address - State:TX
Mailing Address - Zip Code:75860-6081
Mailing Address - Country:US
Mailing Address - Phone:254-625-0310
Mailing Address - Fax:
Practice Address - Street 1:16TH STREET
Practice Address - Street 2:CTMC, BLDG 885
Practice Address - City:FORT LEONARD WOOD
Practice Address - State:MO
Practice Address - Zip Code:65473
Practice Address - Country:US
Practice Address - Phone:573-596-1680
Practice Address - Fax:573-596-0423
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02338363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA02338OtherSTATE LICENSE/PERMIT