Provider Demographics
NPI:1679642227
Name:NIKOLAISEN, ROBERT (PA-C)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
Last Name:NIKOLAISEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 JARRETT WHITE RD
Mailing Address - Street 2:
Mailing Address - City:TRIPLER AMC
Mailing Address - State:HI
Mailing Address - Zip Code:96859-5001
Mailing Address - Country:US
Mailing Address - Phone:808-433-9333
Mailing Address - Fax:
Practice Address - Street 1:1 JARRETT WHITE RD RM 2A701
Practice Address - Street 2:
Practice Address - City:TRIPLER ARMY MEDICAL CENTER
Practice Address - State:HI
Practice Address - Zip Code:96859-5001
Practice Address - Country:US
Practice Address - Phone:808-433-3445
Practice Address - Fax:808-433-6539
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAMD-485363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8447930Medicaid
WA8447930Medicaid
WAQ66286Medicare UPIN