Healthcare Provider Details

I. General information

NPI: 1316037195
Provider Name (Legal Business Name): CHRISTOPHER NICHOLAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 02/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1223 S GEAR AVE SUITE #202
WEST BURLINGTON IA
52655-1682
US

IV. Provider business mailing address

1223 S GEAR AVE SUITE #202
WEST BURLINGTON IA
52655-1682
US

V. Phone/Fax

Practice location:
  • Phone: 319-768-4350
  • Fax:
Mailing address:
  • Phone: 319-768-4350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD34345
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number036112938
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: