Provider Demographics
NPI:1619290822
Name:NWOBODO, NICOLE ELIZABETH ZACK (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ELIZABETH ZACK
Last Name:NWOBODO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:13965 N 75TH AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-6097
Mailing Address - Country:US
Mailing Address - Phone:602-843-2991
Mailing Address - Fax:602-978-1226
Practice Address - Street 1:5605 W EUGIE AVE
Practice Address - Street 2:STE. 200
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85304-1272
Practice Address - Country:US
Practice Address - Phone:602-843-2991
Practice Address - Fax:602-978-1226
Is Sole Proprietor?:No
Enumeration Date:2010-03-03
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ5740363A00000X
MN10711363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant