Provider Demographics
NPI:1114207347
Name:NIEKRO, DENNIS MICHAEL (NP)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:MICHAEL
Last Name:NIEKRO
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX HH
Mailing Address - Street 2:
Mailing Address - City:MONTEREY
Mailing Address - State:CA
Mailing Address - Zip Code:93942
Mailing Address - Country:US
Mailing Address - Phone:831-625-4975
Mailing Address - Fax:831-625-4952
Practice Address - Street 1:23845 HOLMAN HWY STE 315B
Practice Address - Street 2:
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93940-5900
Practice Address - Country:US
Practice Address - Phone:831-625-4975
Practice Address - Fax:831-625-4952
Is Sole Proprietor?:No
Enumeration Date:2011-08-19
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95005341363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95005341OtherNP LICENSE
CA95005341OtherNP LICENSE
CA95005341OtherNP LICENSE