Provider Demographics
NPI:1649264276
Name:MESSAMER, NICHOLAS MARK (MD)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:MARK
Last Name:MESSAMER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:MR
Other - First Name:NICHOLAS
Other - Middle Name:MARK
Other - Last Name:CHRISTENSEN MESSAMER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:410 N 12TH ST
Mailing Address - Street 2:
Mailing Address - City:OSKALOOSA
Mailing Address - State:IA
Mailing Address - Zip Code:52577-2495
Mailing Address - Country:US
Mailing Address - Phone:641-672-3360
Mailing Address - Fax:641-672-3366
Practice Address - Street 1:410 N 12TH ST
Practice Address - Street 2:
Practice Address - City:OSKALOOSA
Practice Address - State:IA
Practice Address - Zip Code:52577-2495
Practice Address - Country:US
Practice Address - Phone:641-672-3360
Practice Address - Fax:641-672-3366
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA27198207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAIA0101OtherJOHN DEERE
7815OtherMIDLAND CHOICE
0000OtherTRICARE
080123337OtherRR MEDICARE
16D0950498OtherCLIA
5008800001OtherCMS
IA46158OtherBLUE CROSS BLUE SHIELD
IA7050880Medicaid
080123337OtherRR MEDICARE
5008800001OtherCMS