Provider Demographics
NPI:1083945893
Name:WALTON, NICOLE PEARL (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:PEARL
Last Name:WALTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:PEARL
Other - Last Name:KNIGHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7 DOCK HILL RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17842-8910
Mailing Address - Country:US
Mailing Address - Phone:570-837-2123
Mailing Address - Fax:570-837-2185
Practice Address - Street 1:246 S MAIN ST
Practice Address - Street 2:
Practice Address - City:HUGHESVILLE
Practice Address - State:PA
Practice Address - Zip Code:17737-1614
Practice Address - Country:US
Practice Address - Phone:570-584-5144
Practice Address - Fax:570-584-4651
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-18
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA054291363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1031848620001Medicaid