Healthcare Provider Details

I. General information

NPI: 1790787984
Provider Name (Legal Business Name): JOHN CHARLES NICHOLSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BOONE RD NAVAL HOSPITAL
BREMERTON WA
98312-1894
US

IV. Provider business mailing address

NAVAL HOSPITAL, ATTN: PROFESSIONAL AFFAIRS (CODE 083F) ONE BOONE ROAD
BREMERTON WA
98312-1898
US

V. Phone/Fax

Practice location:
  • Phone: 360-475-4426
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberJ0160
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: