Jack Philip Nickerson, CRNA

Primary specialty

Certified Registered Nurse AnesthetistTaxonomy code 367500000X

License

4704234290 Issued in MI

Practice address

3333 Evergreen Dr NE
Grand Rapids, MI 49525-9756

Phone

(616) 364-4200

Fax

(616) 364-7347

NPI assigned

Aug 13, 2006

Sex

Male

Sole proprietor

No

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

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

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

• Cardiovascular Anesthesiologists PC

  • Critical Care Medicine (Anesthesiology) Physician
  • Nashville, TN
  • NPI 1912953381

  Nurse Anesthetist, Certified Registered

  NPD (past)

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

{
    "created_epoch": "1155427200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1283126400000",
    "number": "1447262548",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3333 EVERGREEN DR NE",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "495259756",
            "telephone_number": "616-364-4200",
            "fax_number": "616-364-7347"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3333 EVERGREEN DR NE",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "495259756",
            "telephone_number": "616-364-4200",
            "fax_number": "616-364-7347"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "NICKERSON",
        "first_name": "JACK",
        "middle_name": "PHILIP",
        "name_prefix": "Mr.",
        "credential": "CRNA",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-08-13",
        "last_updated": "2010-08-30",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "367500000X",
            "taxonomy_group": "",
            "desc": "Nurse Anesthetist, Certified Registered",
            "state": "MI",
            "license": "4704234290",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "4612272",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Jake Anthony Nicholson, DO
• Joshua Turner Nicholson, D.O.
• Melissa K Nicholson, LMSW
• Tarah Nicholson, DPT
• Ashley Nickell, PA-C
• Robert J Nickerson, PTA
• Jesse Bryan Nicodemus, MOT
• Sonia Nicola
• Lillian Ann Nicolas
• Nicole L Nicolas, MS, CCC-SLP

• Certified Registered Nurse Anesthetist in Grand Rapids, MI
• Providers in Grand Rapids, MI by specialty
• Certified Registered Nurse Anesthetist in Michigan

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 30, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.