Individual
DR. MICHAEL TYSEN NICKLE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DO
Contact information
Practice address
902 LAKEVIEW AVE, PUEBLO, CO 81004-3597
(719) 557-5872
(719) 557-4780
Mailing address
902 LAKEVIEW AVE, PUEBLO, CO 81004-3597
(719) 557-5872
(719) 557-4780
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
TL.0009001
CO
390200000X
Student in an Organized Health Care Education/Training Program
TL.0009001
CO
Other
Enumeration date
06/14/2021
Last updated
06/29/2021
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