Basic Information
| Provider Information | |||||||||
| NPI: | 1508812207 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHERRY | ||||||||
| FirstName: | NICOLA | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5109 | ||||||||
| Address2: | |||||||||
| City: | KLAMATH FALLS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 976010119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418821540 | ||||||||
| FaxNumber: | 5418822583 | ||||||||
| Practice Location | |||||||||
| Address1: | 2580 DAGGETT AVE | ||||||||
| Address2: | |||||||||
| City: | KLAMATH FALLS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 976011127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418841224 | ||||||||
| FaxNumber: | 5418848030 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 03/22/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD21778 | OR | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 288475 | 05 | OR | MEDICAID |