Provider Demographics
NPI:1972787547
Name:SHERRY LYNN NICCOLI MD PC
Entity type:Organization
Organization Name:SHERRY LYNN NICCOLI MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:NICCOLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD PC
Authorized Official - Phone:970-641-2885
Mailing Address - Street 1:PO BOX 1107
Mailing Address - Street 2:
Mailing Address - City:GUNNISON
Mailing Address - State:CO
Mailing Address - Zip Code:81230
Mailing Address - Country:US
Mailing Address - Phone:970-641-2885
Mailing Address - Fax:970-641-2898
Practice Address - Street 1:234 N MAIN ST
Practice Address - Street 2:SUITE 2C
Practice Address - City:GUNNISON
Practice Address - State:CO
Practice Address - Zip Code:81230
Practice Address - Country:US
Practice Address - Phone:970-641-2885
Practice Address - Fax:970-641-2898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-19
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO42817207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO73353213Medicaid
COC800641Medicare PIN
CO73353213Medicaid