Basic Information
| Provider Information | |||||||||
| NPI: | 1992820518 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICKERSON | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | C | ||||||||
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| NameSuffix: | |||||||||
| Credential: | RPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11251 COLOMA RD | ||||||||
| Address2: | STE J | ||||||||
| City: | GOLD RIVER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956704431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9163532270 | ||||||||
| FaxNumber: | 9163532279 | ||||||||
| Practice Location | |||||||||
| Address1: | 2801 K ST | ||||||||
| Address2: | STE 310 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958165120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9163532270 | ||||||||
| FaxNumber: | 9163532279 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | 174400000X | PT12609 | CA | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | PT90581 | 01 | CA | BLUE SHIELD | OTHER | 12300100 | 01 | CA | USDL | OTHER | PT12609 | 01 | CA | BLUE CROSS | OTHER |