Provider Demographics
NPI:1568818268
Name:NODELL, GARRETT EDWARD (PA-C)
Entity Type:Individual
Prefix:MR
First Name:GARRETT
Middle Name:EDWARD
Last Name:NODELL
Suffix:
Gender:M
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 1:2755 HERNDON AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611-6800
Mailing Address - Country:US
Mailing Address - Phone:559-324-4040
Mailing Address - Fax:
Practice Address - Street 1:2755 HERNDON AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611
Practice Address - Country:US
Practice Address - Phone:559-324-4040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-11
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA54441363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant