Provider Demographics
NPI:1306933189
Name:NICHOLS, CHAD L (PA-C)
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:L
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7800 NW 85TH TER
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73132-3385
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5200 E I 240 SERVICE RD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73135-2607
Practice Address - Country:US
Practice Address - Phone:405-628-6000
Practice Address - Fax:405-628-6792
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03727363AS0400X
OK990363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100108590AMedicaid
OKOKA100691Medicare PIN
OK100108590AMedicaid