Healthcare Provider Details

I. General information

NPI: 1003479403
Provider Name (Legal Business Name): NICKERSON ANESTHESIA & NURSING INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2019
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 E SANTA CLARA ST STE 110
ARCADIA CA
91006-7233
US

IV. Provider business mailing address

PO BOX 660257
BIRMINGHAM AL
35266-0257
US

V. Phone/Fax

Practice location:
  • Phone: 626-294-9003
  • Fax:
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 Number
License Number State

VIII. Authorized Official

Name: MR. JOSEPH H NICKERSON IV
Title or Position: PRESIDENT
Credential: CRNA
Phone: 714-658-0091