Provider Demographics
NPI:1386895282
Name:NICHOLS, LIEN T (PA)
Entity type:Individual
Prefix:
First Name:LIEN
Middle Name:T
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6301 HARRIS PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-4245
Mailing Address - Country:US
Mailing Address - Phone:817-877-3432
Mailing Address - Fax:817-346-4394
Practice Address - Street 1:6301 HARRIS PKWY STE 300
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-4245
Practice Address - Country:US
Practice Address - Phone:817-877-3432
Practice Address - Fax:817-346-4394
Is Sole Proprietor?:No
Enumeration Date:2008-10-09
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06749363A00000X
NY012832-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX114141806Medicaid
TX114141806Medicaid
TX270234YKQLMedicare PIN