Provider Demographics
NPI:1568414969
Name:BURWELL, NICOLE BAILEY (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:BAILEY
Last Name:BURWELL
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 1:325 KIPLING ST
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94301-1527
Mailing Address - Country:US
Mailing Address - Phone:504-408-2608
Mailing Address - Fax:
Practice Address - Street 1:1215 WELCH RD # MODULARF
Practice Address - Street 2:
Practice Address - City:STANFORD
Practice Address - State:CA
Practice Address - Zip Code:94305-5102
Practice Address - Country:US
Practice Address - Phone:650-724-0441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110840820363AM0700X
CA54680363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical