Provider Demographics
NPI:1083010052
Name:THIBODEAUX, NICHOLE R (PA-C)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:R
Last Name:THIBODEAUX
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 1:1900 NORTH LOOP W STE 580
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77018-8163
Mailing Address - Country:US
Mailing Address - Phone:713-714-5376
Mailing Address - Fax:
Practice Address - Street 1:1900 NORTH LOOP W STE 580
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77018-8163
Practice Address - Country:US
Practice Address - Phone:713-714-5376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-18
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0003820363AM0700X
TXPA13619363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical