Provider Demographics
NPI:1942260302
Name:NICKUM, CHRISTOPHER W (PA)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:W
Last Name:NICKUM
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10620 TUXFORD DR
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-7067
Mailing Address - Country:US
Mailing Address - Phone:678-393-1509
Mailing Address - Fax:
Practice Address - Street 1:1365A CLIFTON RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-1013
Practice Address - Country:US
Practice Address - Phone:404-778-3481
Practice Address - Fax:404-778-5585
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005050363AS0400X
FLPA3218363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
E1306XMedicare ID - Type Unspecified
FLS64372Medicare UPIN