Provider Demographics
NPI:1992820518
Name:NICKERSON, EDWARD C (RPT)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:C
Last Name:NICKERSON
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11251 COLOMA RD
Mailing Address - Street 2:STE J
Mailing Address - City:GOLD RIVER
Mailing Address - State:CA
Mailing Address - Zip Code:95670-4431
Mailing Address - Country:US
Mailing Address - Phone:916-353-2270
Mailing Address - Fax:916-353-2279
Practice Address - Street 1:2801 K ST
Practice Address - Street 2:STE 310
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5120
Practice Address - Country:US
Practice Address - Phone:916-353-2270
Practice Address - Fax:916-353-2279
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT12609174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT90581OtherBLUE SHIELD
CA12300100OtherUSDL
CAPT12609OtherBLUE CROSS
CAZZZ01587ZMedicare ID - Type UnspecifiedMEDICARE GROUP
CAP00226883Medicare ID - Type UnspecifiedMEDICARE RAILROAD
CAPT90581OtherBLUE SHIELD