Provider Demographics
NPI:1518508001
Name:PLOETZ, NIKKI (PA-C)
Entity Type:Individual
Prefix:
First Name:NIKKI
Middle Name:
Last Name:PLOETZ
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 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-752-0944
Mailing Address - Fax:
Practice Address - Street 1:205 E NASA BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-1950
Practice Address - Country:US
Practice Address - Phone:321-361-5626
Practice Address - Fax:321-723-7196
Is Sole Proprietor?:No
Enumeration Date:2019-10-05
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9112119363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLLY592OtherMEDICARE
FL104738100Medicaid