Provider Demographics
NPI:1649691122
Name:NICKERSON, MICHAEL SCOTT (MS, ARNP-C, COHN-S)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:SCOTT
Last Name:NICKERSON
Suffix:
Gender:M
Credentials:MS, ARNP-C, COHN-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2625 NE 14TH AVE APT 105
Mailing Address - Street 2:
Mailing Address - City:OAKLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33334-4395
Mailing Address - Country:US
Mailing Address - Phone:239-777-9788
Mailing Address - Fax:
Practice Address - Street 1:700 5TH AVE S
Practice Address - Street 2:
Practice Address - City:ST. PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33785
Practice Address - Country:US
Practice Address - Phone:727-767-8404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-30
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3297762363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health