Provider Demographics
NPI:1477297463
Name:MCCANN, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MCCANN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3256 BROOKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549-1922
Mailing Address - Country:US
Mailing Address - Phone:925-818-4278
Mailing Address - Fax:
Practice Address - Street 1:1000 S. FREMONT AVENUE UNIT 7
Practice Address - Street 2:BUILDING A-10, STE. N101
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91803
Practice Address - Country:US
Practice Address - Phone:626-457-4263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-25
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
CA61236363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant