Provider Demographics
NPI:1487832739
Name:NICHOLLS, CORYN I (PA-C)
Entity Type:Individual
Prefix:
First Name:CORYN
Middle Name:I
Last Name:NICHOLLS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CORYN
Other - Middle Name:I
Other - Last Name:MAYERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1601 YGNACIO VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-3122
Mailing Address - Country:US
Mailing Address - Phone:925-947-5399
Mailing Address - Fax:
Practice Address - Street 1:1601 YGNACIO VALLEY RD
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-3122
Practice Address - Country:US
Practice Address - Phone:925-947-5399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-07
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19606363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant