Provider Demographics
NPI:1407858004
Name:MACNICHOLS, JUDY R (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JUDY
Middle Name:R
Last Name:MACNICHOLS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:JUDITH
Other - Middle Name:RUBIELA
Other - Last Name:MACNICHOLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1070 N STONE ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-0919
Mailing Address - Country:US
Mailing Address - Phone:386-943-7100
Mailing Address - Fax:386-943-8909
Practice Address - Street 1:1070 N. STONE STREET
Practice Address - Street 2:SUITE A
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720
Practice Address - Country:US
Practice Address - Phone:386-943-7100
Practice Address - Fax:386-738-8909
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA3264363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL290967700Medicaid
FL290967700Medicaid
P29161Medicare UPIN
FLE5352WMedicare PIN