Provider Demographics
NPI:1457818239
Name:PINE, NICOLE AUTUMN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:AUTUMN
Last Name:PINE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:NICOLE
Other - Middle Name:AUTUMN
Other - Last Name:BRIMHALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:N/A
Mailing Address - Street 1:PO BOX 50095
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98145-5095
Mailing Address - Country:US
Mailing Address - Phone:206-520-5700
Mailing Address - Fax:
Practice Address - Street 1:825 EASTLAKE AVE E
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98109-4405
Practice Address - Country:US
Practice Address - Phone:206-520-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-27
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60993143363A00000X
WA60993143363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2137050Medicaid