Provider Demographics
NPI:1255650107
Name:CRUZ, NICOLE ELIZABETH (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ELIZABETH
Last Name:CRUZ
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 1:2500 N HOUSTON ST
Mailing Address - Street 2:APT 603
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-7655
Mailing Address - Country:US
Mailing Address - Phone:972-250-5700
Mailing Address - Fax:972-250-5748
Practice Address - Street 1:5228 W PLANO PKWY
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-5005
Practice Address - Country:US
Practice Address - Phone:972-250-5700
Practice Address - Fax:972-250-5748
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-18
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTEMPORARY LICENSEOtherTEXAS STATE LICENSE TEMPORARY