Provider Demographics
NPI:1992748263
Name:NICKOLEY, ROSS ALAN (CRNA)
Entity type:Individual
Prefix:MR
First Name:ROSS
Middle Name:ALAN
Last Name:NICKOLEY
Suffix:
Gender:
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12492 AUDRAN RD 9931
Mailing Address - Street 2:
Mailing Address - City:MEXICO
Mailing Address - State:MO
Mailing Address - Zip Code:65265
Mailing Address - Country:US
Mailing Address - Phone:573-590-4046
Mailing Address - Fax:
Practice Address - Street 1:2201 WEST LAMPASASAS ST
Practice Address - Street 2:ENNIS REGIONAL MEDICAL CENTER
Practice Address - City:ENNIS
Practice Address - State:TX
Practice Address - Zip Code:75119
Practice Address - Country:US
Practice Address - Phone:972-875-0900
Practice Address - Fax:469-256-2459
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2025-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN17715367500000X
MO2006005130367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2006005130OtherMO LICENSE