Basic Information
| Provider Information | |||||||||
| NPI: | 1154323194 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICHOLS | ||||||||
| FirstName: | SHARI | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 346 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13790 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077298156 | ||||||||
| FaxNumber: | 6077293982 | ||||||||
| Practice Location | |||||||||
| Address1: | 65 PENNSYLVANIA AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | BINGHAMTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 139031651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077728772 | ||||||||
| FaxNumber: | 6077728796 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2005 | ||||||||
| LastUpdateDate: | 12/27/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | N005456 | NY | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 01901880 | 05 | NY | MEDICAID |