Provider Demographics
NPI:1134688500
Name:ORR, NICOLE RAE (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:RAE
Last Name:ORR
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 1:6575 FIVE POINTS RD
Mailing Address - Street 2:
Mailing Address - City:CREEKSIDE
Mailing Address - State:PA
Mailing Address - Zip Code:15732-8313
Mailing Address - Country:US
Mailing Address - Phone:724-840-5788
Mailing Address - Fax:
Practice Address - Street 1:21911 ROUTE 119
Practice Address - Street 2:
Practice Address - City:PUNXSUTAWNEY
Practice Address - State:PA
Practice Address - Zip Code:15767-7922
Practice Address - Country:US
Practice Address - Phone:814-938-2602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-15
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA060737363A00000X
PAOA006391363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103642841Medicaid