Provider Demographics
NPI:1376306597
Name:NICKEL, ANTONIO (PA-C)
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:
Last Name:NICKEL
Suffix:
Gender:M
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:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-1612
Mailing Address - Fax:239-343-4229
Practice Address - Street 1:13685 DOCTORS WAY STE 100
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4337
Practice Address - Country:US
Practice Address - Phone:239-343-1612
Practice Address - Fax:239-343-4229
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-31
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9118449363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant