Provider Demographics
NPI:1750502043
Name:NILSON, NICOLE MARIE (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:NILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 HOSPITAL PL
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-7559
Mailing Address - Country:US
Mailing Address - Phone:907-714-4502
Mailing Address - Fax:907-714-4696
Practice Address - Street 1:250 HOSPITAL PL
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-6999
Practice Address - Country:US
Practice Address - Phone:907-714-5831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN42203207ZP0102X
AK111775207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1715510Medicaid