Provider Demographics
NPI:1497994529
Name:LONGORIA, NICOLE MARIE (PA)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:MARIE
Last Name:LONGORIA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:KUPINSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:4355 LYMAN AVE
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-8460
Mailing Address - Country:US
Mailing Address - Phone:931-302-0026
Mailing Address - Fax:
Practice Address - Street 1:10207 CERNY ST
Practice Address - Street 2:SUITE 312
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27617-4879
Practice Address - Country:US
Practice Address - Phone:919-670-0302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-12
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1084959363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant