Provider Demographics
NPI:1730187436
Name:NICHOLS, RUSSEL JAMES (MD)
Entity type:Individual
Prefix:
First Name:RUSSEL
Middle Name:JAMES
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:564 E PIONEER DR
Mailing Address - City:HEPPNER
Mailing Address - State:OR
Mailing Address - Zip Code:97836
Mailing Address - Country:US
Mailing Address - Phone:541-676-5504
Mailing Address - Fax:541-676-8247
Practice Address - Street 1:130 THOMPSON AVENUE
Practice Address - Street 2:
Practice Address - City:HEPPNER
Practice Address - State:OR
Practice Address - Zip Code:97836
Practice Address - Country:US
Practice Address - Phone:541-676-5504
Practice Address - Fax:541-676-8247
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD22062207Q00000X, 207P00000X
WAMD00039026207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR287633Medicaid
OR106707OtherMEDICARE PTAN
OR106707OtherMEDICARE PTAN