Provider Demographics
NPI:1306891965
Name:NICKLE, MATTHEW (PT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:NICKLE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 ROBIN HOOD CT
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72764-6822
Mailing Address - Country:US
Mailing Address - Phone:479-871-7337
Mailing Address - Fax:
Practice Address - Street 1:812 ROBIN HOOD CT
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-6822
Practice Address - Country:US
Practice Address - Phone:479-871-7337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARRPT2439246Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Y00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Health Information
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARSW291OtherBLUE CROSS/BLUE SHIELD