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General NPI Number Information
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NPI Number | 1316936156
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Entity Type | Individual
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Provider Name | GARY GLENN NICHOLS P.A.
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Gender | Male
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Dates
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Enumeration Date | 10/14/2005
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Last Update Date | 08/01/2017
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Provider Practice Location Address
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Address Line | 1404 WILLOW LN
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City | NORTH WILKESBORO
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State | NC
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Zip | 28659-3584
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Country | US
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Telephone | 336-667-0335
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Fax | 336-667-4434
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Provider Business Mailing Address
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Address Line | PO BOX 602658
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City | CHARLOTTE
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State | NC
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Zip | 28260-2658
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Country | US
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Telephone | 336-716-2011
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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 | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 100253
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License Number State | NC
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