Provider Demographics
NPI:1316936156
Name:NICHOLS, GARY GLENN (PA)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:GLENN
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 602658
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2658
Mailing Address - Country:US
Mailing Address - Phone:336-716-2011
Mailing Address - Fax:
Practice Address - Street 1:1404 WILLOW LN
Practice Address - Street 2:
Practice Address - City:NORTH WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28659-3584
Practice Address - Country:US
Practice Address - Phone:336-667-0335
Practice Address - Fax:336-667-4434
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2017-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC100253363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2750028COtherMEDICARE PTAN, INDIVIDUAL
NE5905127Medicaid
NC203994FOtherMEDICARE GROUP
NC2335816OtherMEDICARE PTAN, GROUP
NE5905127Medicaid
NC2335816OtherMEDICARE PTAN, GROUP