MEDICARE: DR. TANYA G. NICHOLSON O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	2094	CO

General Provider Information

NPI Number	:	1003877937
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TANYA G. NICHOLSON O.D.

Provider Business Mailing Address
First Line	:	396 N SNOWMASS CIR
Second Line	:
City	:	SUPERIOR
State	:	CO
Zip	:	80027-6124
Country	:	US
Telephone Number	:	303-818-1852
Fax Number	:

Provider Business Practice Location Address
First Line	:	1250 E MAGNOLIA ST
Second Line	:	LOCATED IN WAL-MART
City	:	FT COLLINS
State	:	CO
Zip	:	80524-2754
Country	:	US
Telephone Number	:	970-224-0606
Fax Number	:	970-493-9309

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/30/2006
Last Update Date	:	07/08/2007

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