Provider Demographics
NPI:1285684779
Name:HAVEL, NICOLE M (PA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:HAVEL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 W 12TH ST
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:NE
Mailing Address - Zip Code:69033-3131
Mailing Address - Country:US
Mailing Address - Phone:308-882-7299
Mailing Address - Fax:308-882-7341
Practice Address - Street 1:600 W 12TH ST
Practice Address - Street 2:
Practice Address - City:IMPERIAL
Practice Address - State:NE
Practice Address - Zip Code:69033
Practice Address - Country:US
Practice Address - Phone:308-882-7299
Practice Address - Fax:308-882-7341
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1224363A00000X
FLPA 9105393363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE38608OtherBCBS
249920OtherMIDLANDS CHOICE/MUT OMA
NE280041Medicare PIN
NE38608OtherBCBS