MEDICARE: DR. LAVONNE RAE NICKEL M.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	207L00000X	Anesthesiology Physician	G52307	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00253089	OTHER	CA	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	00G523070	OTHER	CA	BLUE SHIELD OF CA
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1134184021
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAVONNE RAE NICKEL M.D.

Provider Business Mailing Address
First Line	:	10470 OLD PLACERVILLE RD
Second Line	:	SUITE 100
City	:	SACRAMENTO
State	:	CA
Zip	:	95827-2539
Country	:	US
Telephone Number	:	530-320-0296
Fax Number	:

Provider Business Practice Location Address
First Line	:	460 PLUMAS BLVD
Second Line	:	SUITE 202
City	:	YUBA CITY
State	:	CA
Zip	:	95991-5005
Country	:	US
Telephone Number	:	209-956-7732
Fax Number	:	530-749-5520

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

Provider Enumeration Date	:	04/20/2006
Last Update Date	:	10/03/2024

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