Provider Demographics
NPI:1881808780
Name:NICHOLSON, WILL (MD)
Entity type:Individual
Prefix:
First Name:WILL
Middle Name:
Last Name:NICHOLSON
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 1:2590 BITTERSWEET LN
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-2104
Mailing Address - Country:US
Mailing Address - Phone:651-470-5522
Mailing Address - Fax:
Practice Address - Street 1:1414 MARYLAND AVE E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55106-2824
Practice Address - Country:US
Practice Address - Phone:651-722-3461
Practice Address - Fax:651-772-2605
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNNONE207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine