Provider Demographics
NPI:1497284202
Name:NICOLAS, MICHAEL A (NP)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:NICOLAS
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 W CHAPMAN AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-2847
Mailing Address - Country:US
Mailing Address - Phone:714-633-4300
Mailing Address - Fax:
Practice Address - Street 1:1010 W CHAPMAN AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-2847
Practice Address - Country:US
Practice Address - Phone:714-633-4300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-06
Last Update Date:2021-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95079457163W00000X
CA95017723363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse