Provider Demographics
NPI:1508105115
Name:WALZ, NICOLE ANGELA (PA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANGELA
Last Name:WALZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:ANGELA
Other - Last Name:HOFFMANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 488
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:NE
Mailing Address - Zip Code:69022-0488
Mailing Address - Country:US
Mailing Address - Phone:308-697-3329
Mailing Address - Fax:308-697-3278
Practice Address - Street 1:1305 HIGHWAY 6/34
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:NE
Practice Address - Zip Code:69022-6616
Practice Address - Country:US
Practice Address - Phone:308-697-3329
Practice Address - Fax:308-697-3278
Is Sole Proprietor?:No
Enumeration Date:2013-02-04
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE096655006Medicare PIN