Healthcare Provider Details

I. General information

NPI: 1699880179
Provider Name (Legal Business Name): DEBORAH SIMSON NICHOLSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 E NICOLLET BLVD STE 200
BURNSVILLE MN
55337-6732
US

IV. Provider business mailing address

3955 PARKLAWN AVE STE 120
EDINA MN
55435-5655
US

V. Phone/Fax

Practice location:
  • Phone: 952-831-1944
  • Fax: 952-278-6947
Mailing address:
  • Phone: 952-831-1944
  • Fax: 952-278-6947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number38282
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: