Provider Demographics
NPI:1174587075
Name:NICHOLAS, PATRICIA (DPM)
Entity type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:
Last Name:NICHOLAS
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12670 CREEKSIDE LN STE 202
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-3370
Mailing Address - Country:US
Mailing Address - Phone:239-482-2663
Mailing Address - Fax:239-485-7585
Practice Address - Street 1:12670 CREEKSIDE LN STE 202
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-3370
Practice Address - Country:US
Practice Address - Phone:239-482-2663
Practice Address - Fax:239-482-7585
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3946213E00000X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01904470Medicaid
NYU72606Medicare UPIN
NY01904470Medicaid