MEDICARE: JOHN M NICHOLS MD

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	174400000X	Specialist	5111807-1204	UT
2	207V00000X	Obstetrics & Gynecology Physician	511807-1204	UT
3	207V00000X	Obstetrics & Gynecology Physician	6371542	ID

General Provider Information

NPI Number	:	1114906252
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN M NICHOLS MD

Provider Business Mailing Address
First Line	:	190 E BANNOCK ST
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83712-6241
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9850 W ST LUKES DR
Second Line	:
City	:	NAMPA
State	:	ID
Zip	:	83687-7912
Country	:	US
Telephone Number	:	208-381-2267
Fax Number	:	208-381-4314

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

Provider Enumeration Date	:	01/16/2006
Last Update Date	:	02/18/2025

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Directions to “ JOHN M NICHOLS MD” Practice Location

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