Provider Demographics
NPI:1558349910
Name:NICKEL, CAROLYN M (PA)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:M
Last Name:NICKEL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:
Other - Last Name:LAPERRIERE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 446
Mailing Address - Street 2:24 FRANK LLOYD WRIGHT DRIVE
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48106-0446
Mailing Address - Country:US
Mailing Address - Phone:734-747-6766
Mailing Address - Fax:734-220-3100
Practice Address - Street 1:5301 E HURON RIVER DRIVE
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197
Practice Address - Country:US
Practice Address - Phone:734-712-8676
Practice Address - Fax:734-712-3855
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003972363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
N86630010Medicare PIN
MIP89162Medicare UPIN