Provider Demographics
NPI:1154513752
Name:GATHAIYA, NICOLA W (MD)
Entity type:Individual
Prefix:DR
First Name:NICOLA
Middle Name:W
Last Name:GATHAIYA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NICOLA
Other - Middle Name:W
Other - Last Name:MWIRIGI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MBBS
Mailing Address - Street 1:960 E. WALNUT LAWN
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807
Mailing Address - Country:US
Mailing Address - Phone:417-269-4450
Mailing Address - Fax:417-269-8333
Practice Address - Street 1:960 E. WALNUT LAWN
Practice Address - Street 2:SUITE 201
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807
Practice Address - Country:US
Practice Address - Phone:417-269-4450
Practice Address - Fax:417-269-8333
Is Sole Proprietor?:No
Enumeration Date:2007-08-16
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN51914207RE0101X
MO2013003418207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
MNP00864005OtherMEDICARE RAILROAD
IAENROLLEDMedicaid
MNENROLLEDMedicaid