Basic Information
| Provider Information | |||||||||
| NPI: | 1780839605 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICHOLS | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | JAMES | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS, ATC, CSCS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NICHOLS | ||||||||
| OtherFirstName: | DAN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MS, ATC, CSCS | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 520 VALLEY VIEW DR | ||||||||
| Address2: | |||||||||
| City: | MOLINE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612656194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097623621 | ||||||||
| FaxNumber: | 3097623690 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 VALLEY VIEW DR | ||||||||
| Address2: | |||||||||
| City: | MOLINE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612656194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097623621 | ||||||||
| FaxNumber: | 3097623690 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2008 | ||||||||
| LastUpdateDate: | 02/03/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 085005376 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 074769 | IA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 2255A2300X | 0000000865 | TN | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 363AM0700X | 2401 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.