Provider Demographics
NPI:1629352455
Name:ROBERTSON, NICHOLAS BRACKEN (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:BRACKEN
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:NICK
Other - Middle Name:BRACKEN
Other - Last Name:ROBERTSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:280 S MAIN ST
Mailing Address - Street 2:STE 200
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3852
Mailing Address - Country:US
Mailing Address - Phone:714-634-4567
Mailing Address - Fax:
Practice Address - Street 1:280 S MAIN ST
Practice Address - Street 2:STE 200
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3852
Practice Address - Country:US
Practice Address - Phone:714-634-4567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-28
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA126045207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery