Provider Demographics
NPI:1467120451
Name:NACIONALES, NICHOLLE CO (PA-C)
Entity Type:Individual
Prefix:
First Name:NICHOLLE
Middle Name:CO
Last Name:NACIONALES
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 1:4645 TRENTON CIR N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55442-3146
Mailing Address - Country:US
Mailing Address - Phone:763-234-7928
Mailing Address - Fax:
Practice Address - Street 1:4645 TRENTON CIR N
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55442-3146
Practice Address - Country:US
Practice Address - Phone:763-234-7928
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-02
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X, 390200000X
MN14764363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program