Provider Demographics
NPI:1326358482
Name:BACHOVIN, NICOLE MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:BACHOVIN
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 1:3400 SPRUCE ST
Mailing Address - Street 2:1 WEST GATES
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4238
Mailing Address - Country:US
Mailing Address - Phone:215-662-2730
Mailing Address - Fax:
Practice Address - Street 1:3400 SPRUCE ST
Practice Address - Street 2:1 WEST GATES
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4238
Practice Address - Country:US
Practice Address - Phone:215-662-2730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-07
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA054611363AS0400X
NJ25MP00279200363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical