Healthcare Provider Details

I. General information

NPI: 1891051223
Provider Name (Legal Business Name): GRANT S NICHOLS III PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2012
Last Update Date: 12/30/2024
Certification Date: 12/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2685 DUBLIN BLVD
COLORADO SPRINGS CO
80918-1358
US

IV. Provider business mailing address

2695 ROCKY MOUNTAIN AVE STE 150
LOVELAND CO
80538-9071
US

V. Phone/Fax

Practice location:
  • Phone: 719-592-9890
  • Fax: 719-264-7908
Mailing address:
  • Phone: 970-624-2417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0004492
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: