Provider Demographics
NPI:1962131409
Name:NICHOLS, DALTON EDWARD (PA-C)
Entity type:Individual
Prefix:
First Name:DALTON
Middle Name:EDWARD
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 1:125 CROWNE CHASE DR APT 9
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-3579
Mailing Address - Country:US
Mailing Address - Phone:443-257-7540
Mailing Address - Fax:
Practice Address - Street 1:920 CHURCH ST N
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2927
Practice Address - Country:US
Practice Address - Phone:704-403-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-09
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant