Provider Demographics
NPI:1568411841
Name:NICHOLS, LESLIE A (PA)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:A
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:336 29TH ST
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41101-1900
Mailing Address - Country:US
Mailing Address - Phone:606-324-4404
Mailing Address - Fax:606-325-6822
Practice Address - Street 1:21401 ALLEN RD
Practice Address - Street 2:
Practice Address - City:WOODHAVEN
Practice Address - State:MI
Practice Address - Zip Code:48183-1665
Practice Address - Country:US
Practice Address - Phone:734-675-0835
Practice Address - Fax:734-675-0873
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA653363AS0400X
MI5601006720363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q12672Medicare UPIN
0972603Medicare ID - Type Unspecified