Healthcare Provider Details

I. General information

NPI: 1780839605
Provider Name (Legal Business Name): DANIEL JAMES NICHOLS MS, MSM, PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: DAN NICHOLS MS, MSM, PA-C

II. Dates (important events)

Enumeration Date: 11/19/2008
Last Update Date: 04/30/2025
Certification Date: 04/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 10TH ST SE
CEDAR RAPIDS IA
52403-2414
US

IV. Provider business mailing address

202 10TH ST SE STE 140
CEDAR RAPIDS IA
52403-2432
US

V. Phone/Fax

Practice location:
  • Phone: 319-247-3010
  • Fax: 877-303-8768
Mailing address:
  • Phone: 319-398-1545
  • Fax: 309-762-3690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0000000865
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085005376
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2401
License Number StateTN
# 4
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number074769
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: