Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207YS0123X | Facial Plastic Surgeon | M3181 | ID |
NPI | 1275721060 |
---|---|
Provider Name | Dr. Julian O Nicholson |
First Address | Twin Falls, ID 83303-0587 |
Second Address | Twin Falls, ID 83301-3382 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/10/2007 |
Last Update Date | 02/01/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
003855700 | (05) | ID |
C36817 | UPIN (01) | ID |
P00721165 | MCRR (01) | ID |