Basic Information
| Provider Information | |||||||||
| NPI: | 1316262645 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CRALL | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | D. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 605 SKYLINE DR | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805213326 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 711 BARNES AVE | ||||||||
| Address2: | |||||||||
| City: | LA JUNTA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810502138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193845446 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2010 | ||||||||
| LastUpdateDate: | 03/25/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084A0401X | Q1384 | TX | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Medicine | 2084P0800X | 0102203754 | VA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0802X | Q1384 | TX | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Psychiatry | 2084P0800X | OP61249953 | WA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084B0040X | Q1384 | TX | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Behavioral Neurology & Neuropsychiatry |
ID Information
| ID | Type | State | Issuer | Description | Q1384 | 01 | TX | TEXAS LICENSE | OTHER | DR.0063859 | 01 | CO | COLORADO LICENSE | OTHER | 0102203754 | 01 | VA | VIRGINIA LICENSE | OTHER |