Healthcare Provider Details

I. General information

NPI: 1356387484
Provider Name (Legal Business Name): WILLIAM JOHN NICHOLAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 MCINTOSH CIR STE 4
JOPLIN MO
64804-3681
US

IV. Provider business mailing address

PO BOX 3810
JOPLIN MO
64803-3810
US

V. Phone/Fax

Practice location:
  • Phone: 417-347-5000
  • Fax:
Mailing address:
  • Phone: 417-347-6400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number110180
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: