Basic Information
| Provider Information | |||||||||
| NPI: | 1578513552 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICHOLSON | ||||||||
| FirstName: | LAURA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6048 | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977086048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413824900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 865 SW VETERANS WAY | ||||||||
| Address2: | |||||||||
| City: | REDMOND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977562583 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413824900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 01/26/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD179189 | OR | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 500721410 | 05 | OR | MEDICAID |