Healthcare Provider Details

I. General information

NPI: 1063733350
Provider Name (Legal Business Name): TERRY PAUL NICKERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2010
Last Update Date: 08/10/2022
Certification Date: 08/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 RIVERSIDE CIR
ROANOKE VA
24016-4955
US

IV. Provider business mailing address

213 S JEFFERSON ST STE 1006
ROANOKE VA
24011-1713
US

V. Phone/Fax

Practice location:
  • Phone: 540-526-1251
  • Fax:
Mailing address:
  • Phone: 540-224-5715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number0101267266
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: