Provider Demographics
NPI:1447350574
Name:NICHOLS, KEN (PA)
Entity type:Individual
Prefix:
First Name:KEN
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5749 SAN FELIPE ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77057-3101
Mailing Address - Country:US
Mailing Address - Phone:713-972-0800
Mailing Address - Fax:
Practice Address - Street 1:2327 E MULBERRY ST
Practice Address - Street 2:
Practice Address - City:ANGLETON
Practice Address - State:TX
Practice Address - Zip Code:77515-3804
Practice Address - Country:US
Practice Address - Phone:979-848-8070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01042363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8N7577OtherBLUE CROSS BLUE SHIELD