Provider Demographics
NPI:1619040532
Name:NICKENS, LARRY C (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:C
Last Name:NICKENS
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 1:2706 MEDICAL OFFICE PLACE
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-9460
Mailing Address - Country:US
Mailing Address - Phone:919-734-4736
Mailing Address - Fax:919-580-1017
Practice Address - Street 1:2706 MEDICAL OFFICE PLACE
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-9460
Practice Address - Country:US
Practice Address - Phone:919-734-4736
Practice Address - Fax:919-580-1017
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC27762208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
62640OtherBCBS
28723OtherMEDCOST
28723OtherMEDCOST
62640OtherBCBS