Provider Demographics
NPI:1154323194
Name:NICHOLS, SHARI L (DPM)
Entity type:Individual
Prefix:
First Name:SHARI
Middle Name:L
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:346 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790
Mailing Address - Country:US
Mailing Address - Phone:607-729-8156
Mailing Address - Fax:607-729-3982
Practice Address - Street 1:65 PENNSYLVANIA AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13903-1651
Practice Address - Country:US
Practice Address - Phone:607-772-8772
Practice Address - Fax:607-772-8796
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005456213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01901880Medicaid
U71038Medicare UPIN
NY01901880Medicaid