Individual
JOHN ELIOT NICOLAISEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA
Contact information
Practice address
18523 CORWIN RD STE G, APPLE VALLEY, CA 92307-2300
(760) 242-3376
Mailing address
PO BOX 4057, BLUE JAY, CA 92317-4057
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
PA52168
CA
Other
Enumeration date
11/14/2014
Last updated
09/11/2017
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