Basic Information
| Provider Information | |||||||||
| NPI: | 1992098396 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NICOLAU | ||||||||
| FirstName: | DAN | ||||||||
| MiddleName: | ADRIAN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 699 | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN HOME | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376840699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234336039 | ||||||||
| FaxNumber: | 4234336060 | ||||||||
| Practice Location | |||||||||
| Address1: | BUILDING 52, LAKE DRIVE | ||||||||
| Address2: | VA MEDICAL CENTER | ||||||||
| City: | MOUNTAIN HOME | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376840699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234398000 | ||||||||
| FaxNumber: | 4234392200 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2011 | ||||||||
| LastUpdateDate: | 07/20/2015 | ||||||||
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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 | 2084P0800X | 49214 | TN | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 3714470 | 01 | TN | GROUP MEDICARE | OTHER |