Provider Demographics
NPI:1033187026
Name:TALBERT, NICOL CAMPBELL (PA)
Entity Type:Individual
Prefix:
First Name:NICOL
Middle Name:CAMPBELL
Last Name:TALBERT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 E VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:GUNNISON
Mailing Address - State:CO
Mailing Address - Zip Code:81230-2246
Mailing Address - Country:US
Mailing Address - Phone:970-641-0211
Mailing Address - Fax:
Practice Address - Street 1:130 E VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:GUNNISON
Practice Address - State:CO
Practice Address - Zip Code:81230-2246
Practice Address - Country:US
Practice Address - Phone:970-641-0211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10033363A00000X
CO2297363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant