Healthcare Provider Details

I. General information

NPI: 1730187436
Provider Name (Legal Business Name): RUSSEL JAMES NICHOLS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 03/06/2024
Certification Date: 03/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 THOMPSON AVENUE
HEPPNER OR
97836
US

IV. Provider business mailing address

PO BOX 9 564 E PIONEER DR
HEPPNER OR
97836
US

V. Phone/Fax

Practice location:
  • Phone: 541-676-5504
  • Fax: 541-676-8247
Mailing address:
  • Phone: 541-676-5504
  • Fax: 541-676-8247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD22062
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD00039026
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD22062
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: