Provider Demographics
NPI:1699325704
Name:NICHOLS, REGGIE ALLEN (PA-C)
Entity type:Individual
Prefix:
First Name:REGGIE
Middle Name:ALLEN
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 1:7306 S VIA CABANA
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85756-8358
Mailing Address - Country:US
Mailing Address - Phone:928-266-6633
Mailing Address - Fax:
Practice Address - Street 1:3615 N PRINCE VILLAGE PL STE 121
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719-2034
Practice Address - Country:US
Practice Address - Phone:520-225-0584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-19
Last Update Date:2019-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ76312084P0802X, 2084P0800X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction PsychiatryGroup - Single Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty