Provider Demographics
NPI:1578179503
Name:NICKERSON, RYAN PATRICK (NP)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:PATRICK
Last Name:NICKERSON
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 1:3139 N GAYLORD ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80205-4128
Mailing Address - Country:US
Mailing Address - Phone:720-754-4800
Mailing Address - Fax:
Practice Address - Street 1:1719 E 19TH AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80218-1235
Practice Address - Country:US
Practice Address - Phone:303-263-1972
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-15
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPENDING363LA2100X
CO0995952363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care