Healthcare Provider Details

I. General information

NPI: 1497284202
Provider Name (Legal Business Name): MICHAEL A NICOLAS NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2017
Last Update Date: 04/18/2026
Certification Date: 04/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 E CHAPMAN AVE STE 107C
FULLERTON CA
92831-3132
US

IV. Provider business mailing address

2501 E CHAPMAN AVE STE 107C
FULLERTON CA
92831-3132
US

V. Phone/Fax

Practice location:
  • Phone: 562-304-5150
  • Fax: 562-317-1073
Mailing address:
  • Phone: 562-304-5150
  • Fax: 562-317-1073

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95017723
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95079457
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: