Provider Demographics
NPI:1225155427
Name:NICOLAS, ANNA JANE (PA-C)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:JANE
Last Name:NICOLAS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ANNA
Other - Middle Name:
Other - Last Name:PENCHACEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1995 E OAKLAND PARK BLVD STE 310
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33306-1138
Mailing Address - Country:US
Mailing Address - Phone:954-791-6146
Mailing Address - Fax:215-807-8235
Practice Address - Street 1:1995 E OAKLAND PARK BLVD STE 310
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33306-1138
Practice Address - Country:US
Practice Address - Phone:954-791-6146
Practice Address - Fax:954-337-2733
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051562363AS0400X, 363A00000X
FLPA9114245363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant