Healthcare Provider Details

I. General information

NPI: 1093815813
Provider Name (Legal Business Name): ANDREW WILLIAM NICHOLS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1710 EAST-WEST ROAD
HONOLULU HI
96822
US

IV. Provider business mailing address

651 ILALO ST JABSOM, UNIVERSITY OF HAWAII
HONOLULU HI
96813-5525
US

V. Phone/Fax

Practice location:
  • Phone: 808-956-8965
  • Fax:
Mailing address:
  • Phone: 808-956-8965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberMD-8638
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: