Healthcare Provider Details

I. General information

NPI: 1760489389
Provider Name (Legal Business Name): DR. TIMOTHY CHARLES PAIK-NICELY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: TIMOTHY CHARLES NICELY M.D.

II. Dates (important events)

Enumeration Date: 06/29/2005
Last Update Date: 09/20/2023
Certification Date: 09/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2505 LUCAS ST STE B
EUREKA CA
95501-3340
US

IV. Provider business mailing address

2505 LUCAS ST STE B
EUREKA CA
95501-3340
US

V. Phone/Fax

Practice location:
  • Phone: 707-601-9767
  • Fax: 707-601-9746
Mailing address:
  • Phone: 707-601-9767
  • Fax: 707-601-9746

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberG44510
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG44510
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: