Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207R00000X | Internist | 217445 | NY |
Y | 111NI0900X | Internist | 217445 | NY |
N | 208000000X | Pediatrician | 217445 | NY |
NPI | 1013091941 |
---|---|
Provider Name | Timothy Nicholson |
First Address | Latham, NY 12110-2442 |
Second Address | Burnt Hills, NY 12019-1923 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/10/2006 |
Last Update Date | 08/02/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
02349659 | (05) | NY |
H68449 | (02) | NY |