NPIMap

Individual provider Active NPI

Nicholas Wendell Wickersham, M.D.

  • Diagnostic Radiology Physician
  • Boulder, CO
National Provider Identifier
1396867222
Registry record updated Mar 15, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Diagnostic Radiology PhysicianTaxonomy code 2085R0202X
License
47842 Issued in CO
Practice address
1100 Balsam Ave
Boulder, CO 80304-3404
Phone
(303) 532-3500
NPI assigned
Apr 3, 2007
Last updated
Mar 15, 2021By the provider in NPPES
Sex
Male
Sole proprietor
Yes

NPPES NPI Registry

Updated by the provider on Mar 15, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Diagnostic Radiology Physician 2085R0202X 47842 CO Primary

Addresses

Primary practice location

1100 Balsam Ave
Boulder, CO 80304-3404

Mailing address

42 Garden Ctr
Broomfield, CO 80020-1730
Phone (303) 465-0401

Other practice location 1

4747 Arapahoe Ave
Boulder, CO 80303-1131
Phone (877) 465-0012

Other identifiers 1

IdentifierTypeStateIssuer
07101759MedicaidCO

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CO
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20090724000109 CO Practitioner - Diagnostic RadiologyPractitioner - Nuclear MedicinePractitioner - Interventional Radiology 6305919622 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Diagnostic RadiologyAlso: Interventional Radiology, Nuclear Medicine
Education
University of Washington School of Medicine, 2003
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Boulder Radiologists Inc P CGroup PAC ID 4183510274, 13 clinicians

Practice addresses (Care Compare)

4747 Arapahoe Ave
Boulder, CO 80303-1131
Phone (303) 465-0401

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
47842COMDSurgery Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Boulder Radiologists Inc P C Single Specialty CurrentSince Aug 3, 2009 Accepting new patients
Bouldercentre for Orthopedics PC Single Specialty Past Accepting new patients

Locations

1100 Balsam Ave
Boulder, CO 80304
Phone (303) 415-7000

4740 Pearl Pkwy
Ste 110
Boulder, CO 80301

4747 Arapahoe Ave
Boulder, CO 80303
Phone (303) 415-7000

36 Garden Ctr
Broomfield, CO 80020
Phone (303) 465-0401

42 Garden Ctr
Broomfield, CO 80020

Organizations & group practices 2

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 62

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

View all 62

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1175558400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1615766400000",
    "number": "1396867222",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "42 GARDEN CTR",
            "city": "BROOMFIELD",
            "state": "CO",
            "postal_code": "800201730",
            "telephone_number": "303-465-0401",
            "fax_number": "303-438-1351"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1100 BALSAM AVE",
            "city": "BOULDER",
            "state": "CO",
            "postal_code": "803043404",
            "telephone_number": "303-532-3500"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "4747 Arapahoe Ave",
            "address_purpose": "LOCATION",
            "city": "Boulder",
            "state": "CO",
            "postal_code": "803031131",
            "country_code": "US",
            "telephone_number": "877-465-0012",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "WICKERSHAM",
        "first_name": "NICHOLAS",
        "middle_name": "WENDELL",
        "credential": "M.D.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2007-04-03",
        "last_updated": "2021-03-15",
        "certification_date": "2021-03-15",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2085R0202X",
            "taxonomy_group": "",
            "desc": "Radiology, Diagnostic Radiology",
            "state": "CO",
            "license": "47842",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "07101759",
            "state": "CO"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Boulder, CO

Sources for this page

Verify at the official NPI Registry.