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General NPI Number Information
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NPI Number | 1659833366
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Entity Type | Individual
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Provider Name | MATEO F NICHOLSON DO
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Gender | Male
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Dates
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Enumeration Date | 04/02/2019
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Last Update Date | 10/02/2024
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Provider Practice Location Address
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Address Line | 2231 CAREW ST
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City | FORT WAYNE
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State | IN
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Zip | 46805-4713
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Country | US
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Telephone | 260-425-6780
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Fax | 260-373-9225
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Provider Business Mailing Address
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Address Line | 11109 PARKVIEW PLAZA DR # 117
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City | FORT WAYNE
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State | IN
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Zip | 46845-1701
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Country | US
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Telephone |
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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 | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 125074919
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number | 33866
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License Number State | MN
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Taxonomy #3
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State | WI
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Taxonomy #4
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number | 02007853A
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License Number State | IN
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Taxonomy #5
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number | 75957-21
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License Number State | WI
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