Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208000000X | Pediatrician | Q4480 | TX |
Y | 2080P0203X | Pediatric Critical Care Doctor | Q4480 | TX |
NPI | 1144583469 |
---|---|
Provider Name | Blake E Nichols |
First Address | Dallas, TX 75235-7701 |
Second Address | Dallas, TX 75235 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/06/2012 |
Last Update Date | 13/08/2018 |