Provider Demographics
NPI:1548755275
Name:NICKEL, DANE ERIK (MD)
Entity Type:Individual
Prefix:
First Name:DANE
Middle Name:ERIK
Last Name:NICKEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 E. ADAMS STREET
Mailing Address - Street 2:DEPARTMENT OF PEDIATRIC EMERGENCY MEDICINE
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-2306
Mailing Address - Country:US
Mailing Address - Phone:315-464-4363
Mailing Address - Fax:
Practice Address - Street 1:47 NEW SCOTLAND AVENUE
Practice Address - Street 2:DEPARTMENT OF PEDIATRICS
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3412
Practice Address - Country:US
Practice Address - Phone:518-262-6248
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-26
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY64060Medicaid