Individual
DEREK NICHOLS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
117 PONCHA AVE, ALAMOSA, CO 81101-2166
(503) 779-9322
Mailing address
117 PONCHA AVE, ALAMOSA, CO 81101
(503) 779-9322
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
2000018480
OR
Other
Enumeration date
02/19/2016
Last updated
02/19/2016
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