Healthcare Provider Details

I. General information

NPI: 1871277970
Provider Name (Legal Business Name): KEVIN NICKERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2023
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5165 IMPERIAL PKWY
GIRARD PA
16417-9524
US

IV. Provider business mailing address

2314 SASSAFRAS STREET 2ND FLOOR
ERIE PA
16502-2721
US

V. Phone/Fax

Practice location:
  • Phone: 814-774-3128
  • Fax: 814-774-0915
Mailing address:
  • Phone: 412-325-5808
  • Fax: 814-452-7005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD497149
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: