Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207K00000X | Allergist & Immunologist | 4301037905 | MI |
N | 2080P0201X | Pediatric Allergist | 4301037905 | MI |
NPI | 1902982150 |
---|---|
Provider Name | Dr. Peter A Nickles |
First Address | Grosse Pointe Farms, MI 48236 |
Second Address | Grosse Pointe Farms, MI 48236 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/10/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
B46009 | (02) |