MEDICARE: NICOLAS SHANE MEHIS D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RN0300X	Nephrology Physician	20A15690	CA

General Provider Information

NPI Number	:	1770995466
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLAS SHANE MEHIS D.O.

Provider Business Mailing Address
First Line	:	18040 SHERMAN WAY STE 210
Second Line	:
City	:	RESEDA
State	:	CA
Zip	:	91335-4656
Country	:	US
Telephone Number	:	818-796-2920
Fax Number	:	702-399-8431

Provider Business Practice Location Address
First Line	:	18040 SHERMAN WAY STE 210
Second Line	:
City	:	RESEDA
State	:	CA
Zip	:	91335-4656
Country	:	US
Telephone Number	:	818-796-2920
Fax Number	:	702-399-8431

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/29/2014
Last Update Date	:	05/13/2020

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