Provider Demographics
NPI:1528293701
Name:NICHOLSON, ANDREW DAVID (MD)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:DAVID
Last Name:NICHOLSON
Suffix:
Gender:M
Credentials:MD
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 11167
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37939-1167
Mailing Address - Country:US
Mailing Address - Phone:865-584-7376
Mailing Address - Fax:865-540-3856
Practice Address - Street 1:1932 ALCOA HWY STE C360
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37920-1509
Practice Address - Country:US
Practice Address - Phone:865-558-0225
Practice Address - Fax:865-540-3857
Is Sole Proprietor?:No
Enumeration Date:2009-05-18
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101261859207T00000X, 2085R0202X
COCDR.00014252085R0202X
TN59886207T00000X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000188520Medicaid