Basic Information
| Provider Information | |||||||||
| NPI: | 1902085178 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NICOL | ||||||||
| FirstName: | EWEN | ||||||||
| MiddleName: | GEORGE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 36123 SCHOOLCRAFT RD | ||||||||
| Address2: | |||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481501216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344640887 | ||||||||
| FaxNumber: | 7344020254 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 E MEDICAL CENTER DR | ||||||||
| Address2: | B1 FLOOR UNIVERSITY HOSPITAL RECP C | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481090030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349364566 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2007 | ||||||||
| LastUpdateDate: | 07/29/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 5601003768 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | 5601003768 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.