Provider Demographics
NPI:1558312439
Name:NICKELLS, SARAH M (PA-C)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:M
Last Name:NICKELLS
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 1:1123 BRIDLE TRL
Mailing Address - Street 2:
Mailing Address - City:MOON TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:15108-2791
Mailing Address - Country:US
Mailing Address - Phone:724-513-3136
Mailing Address - Fax:
Practice Address - Street 1:1000 DUTCH RIDGE RD
Practice Address - Street 2:
Practice Address - City:BEAVER
Practice Address - State:PA
Practice Address - Zip Code:15009-9727
Practice Address - Country:US
Practice Address - Phone:724-773-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA052249363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAQ66800Medicare UPIN