Provider Demographics
NPI:1396749032
Name:NICHOLSON, TODD R (PA)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:R
Last Name:NICHOLSON
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:PO BOX 647
Mailing Address - Street 2:
Mailing Address - City:VASS
Mailing Address - State:NC
Mailing Address - Zip Code:28394-0647
Mailing Address - Country:US
Mailing Address - Phone:910-245-7678
Mailing Address - Fax:910-245-1444
Practice Address - Street 1:3349 US HWY 1
Practice Address - Street 2:
Practice Address - City:VASS
Practice Address - State:NC
Practice Address - Zip Code:28394
Practice Address - Country:US
Practice Address - Phone:910-245-7678
Practice Address - Fax:910-245-1444
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-10
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103000363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89014UPMedicaid
NC2752855AMedicare ID - Type UnspecifiedMEDICARE
NC89014UPMedicaid