Provider Demographics
NPI:1003986878
Name:SMITH, NICOLE K (PA-C)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:K
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:NICOLE
Other - Middle Name:K
Other - Last Name:DENISI BRANDON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MPASC
Mailing Address - Street 1:3421 CONCORD RD
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402-9001
Mailing Address - Country:US
Mailing Address - Phone:717-339-2710
Mailing Address - Fax:717-339-2711
Practice Address - Street 1:40 V TWIN DR
Practice Address - Street 2:STE 202
Practice Address - City:GETTYSBURG
Practice Address - State:PA
Practice Address - Zip Code:17325-1926
Practice Address - Country:US
Practice Address - Phone:717-339-2710
Practice Address - Fax:717-339-2711
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA050968363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1602843OtherGATEWAY MEDICARE ASSURED
PA2566850OtherHIGHMARK BLUE SHIELD - FREEDOM BLUE
PAMA05096AOtherDEPT OF STATE BUREAU OF P
PA00549500Medicaid
PAMB1004958OtherDEA
D68682Medicare UPIN
00019710Medicare ID - Type Unspecified
PA1602843OtherGATEWAY MEDICARE ASSURED