Provider Demographics
NPI:1609128750
Name:WRIGHT, NICHOLE LYNN (PA)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:LYNN
Last Name:WRIGHT
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 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:920 WOODRUFF RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-4105
Practice Address - Country:US
Practice Address - Phone:864-233-6338
Practice Address - Fax:864-235-1982
Is Sole Proprietor?:No
Enumeration Date:2012-10-12
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2120363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0076347Medicaid
SC1952PAMedicaid
OH50003665OtherOHIO PHYSICIAN ASSISTANT LICENSE
SCPENDINGMedicaid
OH50003665OtherOHIO PHYSICIAN ASSISTANT LICENSE