Provider Demographics
NPI:1114268158
Name:ATACK, NICOLE L (CRNA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:L
Last Name:ATACK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:COOPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 300087
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78703-0002
Mailing Address - Country:US
Mailing Address - Phone:512-558-1443
Mailing Address - Fax:830-885-2670
Practice Address - Street 1:3801 N LAMAR BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78756-4080
Practice Address - Country:US
Practice Address - Phone:512-558-1443
Practice Address - Fax:830-885-2670
Is Sole Proprietor?:No
Enumeration Date:2013-03-14
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX729081367500000X
TXAP123157367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered