| Doctor Name: | WARREN RUSSELL NICKERSON |
| NPI Number: | 1750611794 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | MD |
| License Number: | 29149 |
| Business Practice Address: | 1 Pearl St Brockton, MA - 023012864 |
| Business Phone Number: | 5085844107 |
| Business Fax Number: | |
| Mailing Address: | 24 Hannah Circle, COTUIT |
| State: | MA |
| Postal Code: | 02635 |
| Phone Number: | 5084282085 |
| Fax Number: | |
| NPI Enumeration Date: | 01/13/2010 |
| NPI Last Update Date: | 06/03/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 208D00000X |
| License Number: | 29149 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MA |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | General Practice |
| Taxonomy Specialization: | |
| Taxonomy Definition: | |