Provider Demographics
NPI:1093107641
Name:WHARTON, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:WHARTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:HWA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:151 SOUTHHALL LN
Mailing Address - Street 2:STE 300
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7176
Mailing Address - Country:US
Mailing Address - Phone:407-875-2080
Mailing Address - Fax:407-650-3455
Practice Address - Street 1:1503 BUENOS AIRES BLVD
Practice Address - Street 2:BLDG 100
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32159-6821
Practice Address - Country:US
Practice Address - Phone:352-753-2812
Practice Address - Fax:352-753-5037
Is Sole Proprietor?:No
Enumeration Date:2015-02-19
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108349363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015383600Medicaid
FL015383600Medicaid
FLIC705YMedicare PIN