Provider Demographics
NPI:1942219381
Name:NICKERSON, MICHAEL (NP)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:NICKERSON
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 BORTHWICK AVE
Mailing Address - Street 2:EMERGENCY DEPARTMENT
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801-7128
Mailing Address - Country:US
Mailing Address - Phone:603-433-4012
Mailing Address - Fax:603-433-5184
Practice Address - Street 1:333 BORTHWICK AVE
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-7128
Practice Address - Country:US
Practice Address - Phone:603-433-4012
Practice Address - Fax:603-433-5184
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH033993-23-03363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0711608Medicaid
930112668OtherRAILROAD MEDICARE
ME247490099Medicaid
NH30011603Medicaid
NH4007290Y0NH01OtherANTHEM
MA0711608Medicaid
NH4007290Y0NH01OtherANTHEM
930112668OtherRAILROAD MEDICARE