Active NPI
Nicole Anne Ivan, DO
- Surgery Physician
- Augusta, GA
National Provider Identifier
1386483444
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Surgery Physician
- License
- 16269
- Practice address
- 1459 Laney Walker Boulevard
Ae 3046
Augusta, GA 30912 - Phone
- (706) 721-2503
- NPI assigned
- May 20, 2024
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Surgery Physician | 208600000X | 16269 | GA | Primary |
Addresses
Primary practice location
1459 Laney Walker Boulevard
Ae 3046
Augusta, GA 30912
Mailing address
5 Bailiwick Dr
Warren, NJ 07059-6847
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in GA
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: Yes
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20240725004862 | GA | Order and Referring Only - General Surgery | 4880130863 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Osteopathy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 16269 | GA | MD | Surgery Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1716163200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1716163200000",
"number": "1386483444",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "5 BAILIWICK DR",
"city": "WARREN",
"state": "NJ",
"postal_code": "070596847"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1459 LANEY WALKER BOULEVARD",
"address_2": "AE 3046",
"city": "AUGUSTA",
"state": "GA",
"postal_code": "30912",
"telephone_number": "706-721-2503"
}
],
"practiceLocations": [],
"basic": {
"last_name": "IVAN",
"first_name": "NICOLE",
"middle_name": "ANNE",
"credential": "DO",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2024-05-20",
"last_updated": "2024-05-20",
"certification_date": "2024-05-20",
"status": "A"
},
"taxonomies": [
{
"code": "208600000X",
"taxonomy_group": "",
"desc": "Surgery",
"state": "GA",
"license": "16269",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Augusta, GA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 20, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.