Healthcare Provider Details

I. General information

NPI: 1073288767
Provider Name (Legal Business Name): MARC NICHOLES DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2021
Last Update Date: 06/27/2022
Certification Date: 06/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18511 HIGHLANDER MEDICS STREET
FT. BLISS TX
79918
US

IV. Provider business mailing address

18511 HIGHLANDER MEDICS STREET
FT. BLISS TX
79918
US

V. Phone/Fax

Practice location:
  • Phone: 915-742-0576
  • Fax:
Mailing address:
  • Phone: 915-742-0576
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberBP10081686
License Number StateTX
# 2
Primary TaxonomyY
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: