Healthcare Provider Details

I. General information

NPI: 1699861344
Provider Name (Legal Business Name): PAUL E NICHOLAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 02/04/2021
Certification Date: 02/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 W COLLEGE AVE STE F
SANTA ROSA CA
95401-6506
US

IV. Provider business mailing address

405 W COLLEGE AVE STE F
SANTA ROSA CA
95401-6506
US

V. Phone/Fax

Practice location:
  • Phone: 707-547-5450
  • Fax: 707-573-3555
Mailing address:
  • Phone: 707-547-5450
  • Fax: 707-573-3555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberA98793
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number47520
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: