Provider Demographics
NPI:1215931613
Name:CREEL, NICHOLAS B (MD ,PA)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:B
Last Name:CREEL
Suffix:
Gender:M
Credentials:MD ,PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 OAK DR S
Mailing Address - Street 2:STE A
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566-5617
Mailing Address - Country:US
Mailing Address - Phone:979-297-1241
Mailing Address - Fax:979-297-5692
Practice Address - Street 1:215 OAK DR S
Practice Address - Street 2:STE A
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-5617
Practice Address - Country:US
Practice Address - Phone:979-297-1241
Practice Address - Fax:979-297-5692
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-13
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE1833174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX035580201Medicaid
TX00R280Medicare ID - Type Unspecified
TXB22018Medicare UPIN