Healthcare Provider Details

I. General information

NPI: 1528461720
Provider Name (Legal Business Name): KYLE NICKEL MD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2014
Last Update Date: 10/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95 STAFFORD LN
DELTA CO
81416-3465
US

IV. Provider business mailing address

95 STAFFORD LN
DELTA CO
81416-3465
US

V. Phone/Fax

Practice location:
  • Phone: 970-874-8026
  • Fax:
Mailing address:
  • Phone: 970-874-8026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number33012
License Number StateCO

VIII. Authorized Official

Name: DR. KYLE CHRISTIAN NICKEL
Title or Position: PRESIDENT
Credential: M.D.
Phone: 303-929-1609