Individual
GARY GLENN NICHOLS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
P.A.
Contact information
Practice address
1404 WILLOW LN, NORTH WILKESBORO, NC 28659-3584
(336) 667-0335
(336) 667-4434
Mailing address
PO BOX 602658, CHARLOTTE, NC 28260-2658
(336) 716-2011
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
100253
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
203994F
MEDICARE GROUP
NC
01
—
2335816
MEDICARE PTAN, GROUP
NC
01
—
2750028C
MEDICARE PTAN, INDIVIDUAL
NC
05
—
5905127
—
NE
Enumeration date
10/14/2005
Last updated
08/01/2017
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