Provider Demographics
NPI:1982922001
Name:NICKERSON, DAVID (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
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 1:1333 W 5TH ST STE 110
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-2752
Mailing Address - Country:US
Mailing Address - Phone:307-675-5850
Mailing Address - Fax:
Practice Address - Street 1:1401 W 5TH ST
Practice Address - Street 2:SHERIDAN MEMORIAL HOSPITAL EMERGENCY DEPT
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-2705
Practice Address - Country:US
Practice Address - Phone:512-569-3696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-13
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY9222A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine