1295816692 NPI number — DR. RONALD WAYNE NICHOLAS DPH

Table of content: DR. RONALD WAYNE NICHOLAS DPH (NPI 1295816692)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295816692 NPI number — DR. RONALD WAYNE NICHOLAS DPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NICHOLAS
Provider First Name:
RONALD
Provider Middle Name:
WAYNE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPH
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
NICHOLAS
Provider Other First Name:
RONALD
Provider Other Middle Name:
WAYNE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DPH
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1295816692
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/23/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1106 SE 10TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAGONER
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74467-7218
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-485-3267
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
326 E CHEROKEE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAGONER
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74467-4706
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-485-2317
Provider Business Practice Location Address Fax Number:
918-485-8483
Provider Enumeration Date:
10/18/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  7404 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)