Basic Information
| Provider Information | |||||||||
| NPI: | 1780643742 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NICHOLAS | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | PETER | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1505 53RD AVE E | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342034249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9413577950 | ||||||||
| FaxNumber: | 9418401003 | ||||||||
| Practice Location | |||||||||
| Address1: | 1505 53RD AVE E | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342034249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9413577950 | ||||||||
| FaxNumber: | 9418401003 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2006 | ||||||||
| LastUpdateDate: | 02/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME140408 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 202193207 | 05 | MO | MEDICAID |