Healthcare Provider Details

I. General information

NPI: 1023019205
Provider Name (Legal Business Name): BRENT G NICK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 E WHITESTONE BLVD STE C
CEDAR PARK TX
78613-7558
US

IV. Provider business mailing address

6210 E HIGHWAY 290
AUSTIN TX
78723-1142
US

V. Phone/Fax

Practice location:
  • Phone: 512-259-3467
  • Fax:
Mailing address:
  • Phone: 512-483-9596
  • Fax: 512-406-6216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberQ8978
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number40214
License Number StateNH
# 3
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number019461
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: