Healthcare Provider Details

I. General information

NPI: 1942260302
Provider Name (Legal Business Name): CHRISTOPHER W NICKUM P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1365A CLIFTON RD NE
ATLANTA GA
30322-1013
US

IV. Provider business mailing address

10620 TUXFORD DR
ALPHARETTA GA
30022-7067
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-3481
  • Fax: 404-778-5585
Mailing address:
  • Phone: 678-393-1509
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number005050
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA3218
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: