Provider Demographics
NPI:1134156359
Name:CHAISSON, NICOLE (MD)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:
Last Name:CHAISSON
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 1:2020 E 28TH ST.
Mailing Address - Street 2:UMPHYSICIANS SMILEY'S CLINIC
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407
Mailing Address - Country:US
Mailing Address - Phone:612-333-0770
Mailing Address - Fax:612-333-1986
Practice Address - Street 1:2020 E 28TH ST.
Practice Address - Street 2:UFP SMILEY'S CLINIC
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407
Practice Address - Country:US
Practice Address - Phone:612-333-0770
Practice Address - Fax:612-333-1986
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN44929207Q00000X, 207QA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0586313Medicaid
MN171902OtherUCARE
MN01-19354OtherMEDICA CHOICE & PRIMARY
MN2298998OtherARAZ
MN551T1CHOtherBCBS
MN1034699OtherPREFERRED ONE
MNHP39171OtherHEALTHPARTNERS
MN551T1CHOtherBCBS
MNH88342Medicare UPIN
MNP00247941Medicare ID - Type UnspecifiedRAILROAD MEDICARE
MN080013674Medicare ID - Type UnspecifiedMN MEDICARE
MN1034699OtherPREFERRED ONE