Provider Demographics
NPI:1891051223
Name:NICHOLS, GRANT S III (PA-C)
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:S
Last Name:NICHOLS
Suffix:III
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2695 ROCKY MOUNTAIN AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-9071
Mailing Address - Country:US
Mailing Address - Phone:970-624-2417
Mailing Address - Fax:
Practice Address - Street 1:2685 DUBLIN BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-1358
Practice Address - Country:US
Practice Address - Phone:719-592-9890
Practice Address - Fax:719-264-7908
Is Sole Proprietor?:No
Enumeration Date:2012-04-10
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246ZE0600X
COPA.0004492363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic