Provider Demographics
NPI:1053491753
Name:RAULERSON, NICHOL (PA)
Entity Type:Individual
Prefix:MRS
First Name:NICHOL
Middle Name:
Last Name:RAULERSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:NICHOL
Other - Middle Name:CHRISTINE
Other - Last Name:ALLEGRETTI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:620 10TH ST N STE 3A
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33705-1407
Mailing Address - Country:US
Mailing Address - Phone:727-824-7105
Mailing Address - Fax:727-824-7125
Practice Address - Street 1:620 10TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33705-1407
Practice Address - Country:US
Practice Address - Phone:727-824-7105
Practice Address - Fax:727-824-7125
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103943363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010042400Medicaid