Provider Demographics
NPI:1801405626
Name:NICHOLSON, ANTHONY MARK
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:MARK
Last Name:NICHOLSON
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 1:1239 SOLITAIRE ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80905-4206
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1650 COCHRANE CIR BLDG 7505
Practice Address - Street 2:
Practice Address - City:FORT CARSON
Practice Address - State:CO
Practice Address - Zip Code:80913-4613
Practice Address - Country:US
Practice Address - Phone:719-526-2361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-28
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program