Provider Demographics
NPI:1235759259
Name:SALAS, NIKOLE
Entity Type:Individual
Prefix:
First Name:NIKOLE
Middle Name:
Last Name:SALAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6200 SW 72ND ST STE 502
Mailing Address - Street 2:
Mailing Address - City:SOUTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-4830
Mailing Address - Country:US
Mailing Address - Phone:305-271-9777
Mailing Address - Fax:
Practice Address - Street 1:6200 SW 72ND ST STE 502
Practice Address - Street 2:
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-4830
Practice Address - Country:US
Practice Address - Phone:305-271-9777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-20
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9114946363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant