Provider Demographics
NPI:1578740247
Name:NICHOLSON, RICHARD JESSE
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:JESSE
Last Name:NICHOLSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1041 E RIVER DR
Mailing Address - Street 2:
Mailing Address - City:LAKE LUZERNE
Mailing Address - State:NY
Mailing Address - Zip Code:12846-2305
Mailing Address - Country:US
Mailing Address - Phone:518-964-6773
Mailing Address - Fax:518-964-6735
Practice Address - Street 1:1041 E RIVER DR
Practice Address - Street 2:
Practice Address - City:LAKE LUZERNE
Practice Address - State:NY
Practice Address - Zip Code:12846-2305
Practice Address - Country:US
Practice Address - Phone:518-964-6773
Practice Address - Fax:518-964-6735
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-24
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies