Provider Demographics
NPI:1356843684
Name:FITTS, NICOLE K (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:K
Last Name:FITTS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:K
Other - Last Name:NATHE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2115 S FREMONT AVE STE 3300
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-2246
Mailing Address - Country:US
Mailing Address - Phone:417-820-5200
Mailing Address - Fax:
Practice Address - Street 1:2115 S FREMONT AVE STE 3300
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2246
Practice Address - Country:US
Practice Address - Phone:417-820-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-02
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018006454363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO220051469Medicaid