Provider Demographics
NPI:1053444679
Name:SMITH, NICHOLE M (PA-C)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
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 1:7200 WYOMING SPGS
Mailing Address - Street 2:SUITE 600
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78681-4303
Mailing Address - Country:US
Mailing Address - Phone:512-244-1995
Mailing Address - Fax:512-244-2090
Practice Address - Street 1:7200 WYOMING SPGS
Practice Address - Street 2:SUITE 600
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78681-4303
Practice Address - Country:US
Practice Address - Phone:512-244-1995
Practice Address - Fax:512-244-2090
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02319363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA02319OtherSTATE LICENSE NUMBER