Provider Demographics
NPI:1386091130
Name:NICKERSON, JOSHUA (DO)
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:NICKERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-9800
Mailing Address - Country:US
Mailing Address - Phone:570-271-6211
Mailing Address - Fax:
Practice Address - Street 1:4641 E ROOSEVELT BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19124-2343
Practice Address - Country:US
Practice Address - Phone:800-889-0548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-23
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.00684322084P0800X
PA390200000X
PAOS0198142084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program