Provider Demographics
NPI:1598958035
Name:GILL, NICHOLE R (PA)
Entity Type:Individual
Prefix:MS
First Name:NICHOLE
Middle Name:R
Last Name:GILL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 S MAIN ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45409-2698
Mailing Address - Country:US
Mailing Address - Phone:937-228-5115
Mailing Address - Fax:937-228-4591
Practice Address - Street 1:1520 S MAIN ST
Practice Address - Street 2:SUITE 200
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-2698
Practice Address - Country:US
Practice Address - Phone:937-228-5115
Practice Address - Fax:937-228-4591
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-18
Last Update Date:2007-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2642363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical