Basic Information
| Provider Information | |||||||||
| NPI: | 1811948672 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICKLES | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.P.M. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 915 13TH AVE N | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | IA | ||||||||
| PostalCode: | 527325067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5632432511 | ||||||||
| FaxNumber: | 5632430817 | ||||||||
| Practice Location | |||||||||
| Address1: | 915 13TH AVE N | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | IA | ||||||||
| PostalCode: | 527325067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5632432511 | ||||||||
| FaxNumber: | 5632430817 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2006 | ||||||||
| LastUpdateDate: | 03/15/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 00766 | IA | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 118341 | 01 | HEALTH ALLIANCE | OTHER | BN9116535 | 01 | IA | DEA REGISTRATION NUMBER | OTHER | IA01C1 | 01 | JOHN DEERE HEALTH CARE / | OTHER | 0491662 | 05 | IA | MEDICAID | 15422 | 01 | IA | WELLMARK BC/BS | OTHER | 250822 | 01 | MIDLANDS CHOICE | OTHER |