Provider Demographics
NPI:1043235484
Name:NICKEL, GRAIG L (MD)
Entity type:Individual
Prefix:
First Name:GRAIG
Middle Name:L
Last Name:NICKEL
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 1:3916 PRAIRIE ROSE ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66049-7825
Mailing Address - Country:US
Mailing Address - Phone:785-856-0025
Mailing Address - Fax:
Practice Address - Street 1:1200 SCHWEGLER DRIVE
Practice Address - Street 2:KU SHS - WATKINS MEMORIAL HEALTH CENTER
Practice Address - City:LINDSBORG
Practice Address - State:KS
Practice Address - Zip Code:66045
Practice Address - Country:US
Practice Address - Phone:785-864-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2013-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-28982207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100409080BMedicaid
102088Medicare ID - Type Unspecified
H30174Medicare UPIN