Healthcare Provider Details

I. General information

NPI: 1326014820
Provider Name (Legal Business Name): ANDREW J. NICKS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2006
Last Update Date: 06/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 TRANCAS STREET
NAPA CA
94558-2906
US

IV. Provider business mailing address

PO BOX 348120
SACRAMENTO CA
95834
US

V. Phone/Fax

Practice location:
  • Phone: 707-252-4411
  • Fax: 707-252-2240
Mailing address:
  • Phone: 707-252-4633
  • Fax: 707-252-2240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberG24715
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: