Provider Demographics
NPI:1376724047
Name:OVERBECK, NICOLE SUSAN (PA)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:SUSAN
Last Name:OVERBECK
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 1:4685 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45212-3397
Mailing Address - Country:US
Mailing Address - Phone:513-246-1964
Mailing Address - Fax:
Practice Address - Street 1:6350 GLENWAY AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45211-6378
Practice Address - Country:US
Practice Address - Phone:513-347-6922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-21
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.001315RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000613841OtherANTHEM
OH0225920002Medicare NSC
OHPA30432Medicare PIN
OH0069511Medicaid
OHH154160Medicare PIN