Basic Information
| Provider Information | |||||||||
| NPI: | 1427793025 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NICHOLS | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | NEAL | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 425 WASHINGTON ST APT 308 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641051115 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3550 S 4TH ST | ||||||||
| Address2: | |||||||||
| City: | LEAVENWORTH | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660485071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9136806100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2022 | ||||||||
| LastUpdateDate: | 11/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 146N00000X | B-64544 | MO | N | Emergency Medical Service Providers | Emergency Medical Technician, Basic | 363A00000X | 2021034610 | MO | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 15-02665 | KS | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.