Provider Demographics
NPI:1821057175
Name:NICOL, WILLIAM C (CRNA)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:C
Last Name:NICOL
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2411
Mailing Address - Street 2:
Mailing Address - City:RED LODGE
Mailing Address - State:MT
Mailing Address - Zip Code:59068-2411
Mailing Address - Country:US
Mailing Address - Phone:406-853-5480
Mailing Address - Fax:
Practice Address - Street 1:819 LOWER CONTINENTAL
Practice Address - Street 2:# 2
Practice Address - City:RED LODGE
Practice Address - State:MT
Practice Address - Zip Code:59068-2411
Practice Address - Country:US
Practice Address - Phone:406-853-5480
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT12289367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0433953Medicaid
MT0433953Medicaid