Basic Information
Provider Information | |||||||||
NPI: | 1306933189 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NICHOLS | ||||||||
FirstName: | CHAD | ||||||||
MiddleName: | L. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7800 NW 85TH TER | ||||||||
Address2: |   | ||||||||
City: | OKLAHOMA CITY | ||||||||
State: | OK | ||||||||
PostalCode: | 731323385 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 5200 E I 240 SERVICE RD | ||||||||
Address2: |   | ||||||||
City: | OKLAHOMA CITY | ||||||||
State: | OK | ||||||||
PostalCode: | 731352607 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4056286000 | ||||||||
FaxNumber: | 4056286792 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/05/2006 | ||||||||
LastUpdateDate: | 10/26/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/26/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PA03727 | TX | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 990 | OK | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 100108590A | 05 | OK |   | MEDICAID |