MEDICARE: NICHOLAS WILLIAM GONZALES

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	ODP-100620	ID

General Provider Information

NPI Number	:	1538858279
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLAS WILLIAM GONZALES

Provider Business Mailing Address
First Line	:	1906 FAIRVIEW AVE STE 100
Second Line	:
City	:	CALDWELL
State	:	ID
Zip	:	83605-5433
Country	:	US
Telephone Number	:	208-459-2020
Fax Number	:

Provider Business Practice Location Address
First Line	:	1906 FAIRVIEW AVE STE 100
Second Line	:
City	:	CALDWELL
State	:	ID
Zip	:	83605-5433
Country	:	US
Telephone Number	:	208-459-2020
Fax Number	:

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

Provider Enumeration Date	:	05/08/2023
Last Update Date	:	07/19/2023

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