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General NPI Number Information
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NPI Number | 1063041960
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Entity Type | Individual
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Provider Name | ANDREW GORDON NICHOLSON MD
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Gender | Male
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Dates
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Enumeration Date | 04/03/2020
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Last Update Date | 11/07/2025
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Provider Practice Location Address
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Address Line | 7559 ODAY LN NE
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City | OTSEGO
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State | MN
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Zip | 55330-6314
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Country | US
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Telephone | 612-214-0386
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 132
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City | ROGERS
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State | MN
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Zip | 55374-0132
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Country | US
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Telephone | 913-498-6537
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 79893
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License Number State | MN
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