Healthcare Provider Details

I. General information

NPI: 1396279378
Provider Name (Legal Business Name): COOPER L NICKEL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2017
Last Update Date: 12/07/2025
Certification Date: 12/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

761 W 175TH ST S
CALDWELL KS
67022-8301
US

IV. Provider business mailing address

4612 HEARTHSIDE DR
LAWRENCE KS
66049-3740
US

V. Phone/Fax

Practice location:
  • Phone: 620-845-6492
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number04-41127
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number04-41127
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: