Provider Demographics
NPI:1477710101
Name:BARKOFF, NICHOLE THERESE (PAC)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:THERESE
Last Name:BARKOFF
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:947-522-1863
Mailing Address - Fax:947-522-0307
Practice Address - Street 1:23715 LITTLE MACK AVE STE 100
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-1181
Practice Address - Country:US
Practice Address - Phone:586-447-8021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-20
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005239363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601005239OtherLICENSE