Healthcare Provider Details

I. General information

NPI: 1376826925
Provider Name (Legal Business Name): WILLIAM DAVID NICKELL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: DAVE NICKELL PA-C

II. Dates (important events)

Enumeration Date: 09/20/2011
Last Update Date: 09/24/2025
Certification Date: 09/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MEDICAL CENTER DR
SPRINGFIELD OH
45504-2687
US

IV. Provider business mailing address

100 MEDICAL CENTER DR
SPRINGFIELD OH
45504-2687
US

V. Phone/Fax

Practice location:
  • Phone: 937-523-9885
  • Fax: 937-523-9887
Mailing address:
  • Phone: 937-523-9885
  • Fax: 937-523-9887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number003357
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number003357
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPAC1180
License Number StateND
# 4
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number003357
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: