Provider Demographics
NPI:1699185660
Name:ROCKEFELLER, NICHOLAS F
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:F
Last Name:ROCKEFELLER
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 1:6420 CLAYTON RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63117-1811
Mailing Address - Country:US
Mailing Address - Phone:314-768-8000
Mailing Address - Fax:314-645-8771
Practice Address - Street 1:6100 PAN AMERICAN FREEWAY NE
Practice Address - Street 2:STE 450
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-3460
Practice Address - Country:US
Practice Address - Phone:505-823-8787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-30
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014020090207V00000X
NMRS2018-0404207VF0040X
NM390200000X
390200000X
NMMD2021-0817207VF0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyFemale Pelvic Medicine and Reconstructive Surgery
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program