Basic Information
| Provider Information | |||||||||
| NPI: | 1235205386 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICHOLAS, NP | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | ALAN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MSN, NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1634 GULL RD | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490481632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699032835 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 OAKLAND DR | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490081282 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693376200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 12/06/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 4704140236 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 4704140236 | 01 | MI | MI LICENSE | OTHER |