Provider Demographics
NPI:1124098785
Name:NICHOLS, KEITH ANDREW (MD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:ANDREW
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 TEMPLE ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:OWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13827-1421
Mailing Address - Country:US
Mailing Address - Phone:607-687-5616
Mailing Address - Fax:607-687-5989
Practice Address - Street 1:130 TEMPLE ST
Practice Address - Street 2:SUITE 100
Practice Address - City:OWEGO
Practice Address - State:NY
Practice Address - Zip Code:13827-1421
Practice Address - Country:US
Practice Address - Phone:607-687-5616
Practice Address - Fax:607-687-5989
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2007-10-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY141416207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBA0719Medicare PIN
NYRA8789Medicare PIN
NYB82245Medicare UPIN