Provider Demographics
NPI:1699861344
Name:NICHOLAS, PAUL E (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:E
Last Name:NICHOLAS
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 1:405 W COLLEGE AVE STE F
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-6506
Mailing Address - Country:US
Mailing Address - Phone:707-547-5450
Mailing Address - Fax:707-573-3555
Practice Address - Street 1:405 W COLLEGE AVE STE F
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-6506
Practice Address - Country:US
Practice Address - Phone:707-547-5450
Practice Address - Fax:707-573-3555
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI475202084P0800X
CAA987932084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34606500Medicaid
WI34606500Medicaid