Healthcare Provider Details

I. General information

NPI: 1609987502
Provider Name (Legal Business Name): CHARLES HATHAWAY NICHOLSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 12/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4420 LAKE BOONE TRL
RALEIGH NC
27607-7505
US

IV. Provider business mailing address

PO BOX 18139
RALEIGH NC
27619-8139
US

V. Phone/Fax

Practice location:
  • Phone: 919-784-3034
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number30439
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number30439
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: