Provider Demographics
NPI:1811950843
Name:NICKERSON, JAMES MAYNARD (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:MAYNARD
Last Name:NICKERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:590 COURT ST
Mailing Address - Street 2:
Mailing Address - City:KEENE
Mailing Address - State:NH
Mailing Address - Zip Code:03431-1719
Mailing Address - Country:US
Mailing Address - Phone:603-354-5466
Mailing Address - Fax:603-354-5468
Practice Address - Street 1:590 COURT ST
Practice Address - Street 2:
Practice Address - City:KEENE
Practice Address - State:NH
Practice Address - Zip Code:03431-1719
Practice Address - Country:US
Practice Address - Phone:603-354-5466
Practice Address - Fax:603-354-5468
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH9781207RH0000X, 207RX0202X
VT0420009373207RH0000X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30009784Medicaid
NH30009784Medicaid
NHCX8605Medicare PIN