Provider Demographics
NPI:1164122214
Name:BOCK, NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BOCK
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:PO BOX 658
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30503-0658
Mailing Address - Country:US
Mailing Address - Phone:770-718-1122
Mailing Address - Fax:770-533-4786
Practice Address - Street 1:155 PROFESSIONAL DRIVE
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:GA
Practice Address - Zip Code:30511-4000
Practice Address - Country:US
Practice Address - Phone:706-776-2368
Practice Address - Fax:706-776-2589
Is Sole Proprietor?:No
Enumeration Date:2023-03-07
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11755363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant