Provider Demographics
NPI:1447798111
Name:KLOPOVIC, NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:KLOPOVIC
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:PO BOX 580823
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-0014
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9045 BRUCEVILLE RD STE 100
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-5950
Practice Address - Country:US
Practice Address - Phone:916-479-9110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-02
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54175363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant