Healthcare Provider Details

I. General information

NPI: 1942992128
Provider Name (Legal Business Name): BRIAN CLAYTON NICKLES DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2023
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 S KY HIGHWAY 15
HAZARD KY
41701-6029
US

IV. Provider business mailing address

30 S KY HIGHWAY 15
HAZARD KY
41701-6029
US

V. Phone/Fax

Practice location:
  • Phone: 606-629-5298
  • Fax: 606-249-8333
Mailing address:
  • Phone: 606-629-5299
  • Fax: 606-249-8333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number06164
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: