Healthcare Provider Details

I. General information

NPI: 1053369934
Provider Name (Legal Business Name): THOMAS M NICHOLS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 07/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 48TH ST
VALLEY AL
36854-3666
US

IV. Provider business mailing address

PO BOX 661495
BIRMINGHAM AL
35266-1495
US

V. Phone/Fax

Practice location:
  • Phone: 334-756-1848
  • Fax: 334-756-1854
Mailing address:
  • Phone: 205-979-5882
  • Fax: 205-979-1248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1-059468
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: