Healthcare Provider Details

I. General information

NPI: 1164412094
Provider Name (Legal Business Name): SHAWNN D NICHOLS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2005
Last Update Date: 09/26/2024
Certification Date: 09/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7400 MERTON MINTER BLVD MEDICAL STAFF OFFICE (11M)
SAN ANTONIO TX
78229-4404
US

IV. Provider business mailing address

3551 ROGER BROOKE DR
FORT SAM HOUSTON TX
78234-4504
US

V. Phone/Fax

Practice location:
  • Phone: 210-616-8385
  • Fax: 210-443-0322
Mailing address:
  • Phone: 210-916-3334
  • Fax: 210-916-2202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number36084412
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number35.084414
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: