Provider Demographics
NPI:1538191465
Name:NIKKEL, RICHARD LEE (CRNA)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:LEE
Last Name:NIKKEL
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 HARROGATE LN
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-8727
Mailing Address - Country:US
Mailing Address - Phone:229-227-1928
Mailing Address - Fax:
Practice Address - Street 1:2282 E PINETREE BLVD
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-4807
Practice Address - Country:US
Practice Address - Phone:229-228-4988
Practice Address - Fax:229-226-5859
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN072148367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA430062644OtherRAILROAD MEDICARE
GAR80061Medicare UPIN
GA43ZCBXG01Medicare PIN
GA43ZCBZZ01Medicare PIN