Basic Information
| Provider Information | |||||||||
| NPI: | 1033223318 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NICHOLSON | ||||||||
| FirstName: | CRAIG | ||||||||
| MiddleName: | ALAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 PRESTIGE PL STE 550 | ||||||||
| Address2: | |||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453426115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377621310 | ||||||||
| FaxNumber: | 9375228493 | ||||||||
| Practice Location | |||||||||
| Address1: | 1258 BELLEFONTAINE ST | ||||||||
| Address2: | |||||||||
| City: | WAPAKONETA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458959775 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197391980 | ||||||||
| FaxNumber: | 4197391982 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2006 | ||||||||
| LastUpdateDate: | 10/28/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 01088864A | IN | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | 4301090624 | MI | N | Allopathic & Osteopathic Physicians | Urology | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208800000X | 35096239 | OH | Y | Allopathic & Osteopathic Physicians | Urology |
No ID Information.