Provider Demographics
NPI:1770648578
Name:NICKERSON, JOSEPH H IV (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:H
Last Name:NICKERSON
Suffix:IV
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:JOSEPH
Other - Middle Name:HOWARD
Other - Last Name:NICKERSON
Other - Suffix:IV
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 660257
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35266-0257
Mailing Address - Country:US
Mailing Address - Phone:205-979-5882
Mailing Address - Fax:205-979-1248
Practice Address - Street 1:255 E SANTA CLARA ST STE 110
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91006-7233
Practice Address - Country:US
Practice Address - Phone:626-294-9003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA499960RN163W00000X
CANA2569367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2569OtherCRNA
CA499960OtherRN
CAWNA2569BMedicaid
CA499960OtherRN
CA2569OtherCRNA