Provider Demographics
NPI:1508316647
Name:GUDGEON, NICHOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:GUDGEON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3801 SCOTT AND WHITE DR
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76543-5252
Practice Address - Country:US
Practice Address - Phone:254-680-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-13
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2613363A00000X
MO2018004237363A00000X
AZ7448363A00000X
TXPA13699363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant