Provider Demographics
NPI:1619908381
Name:BURGBACHER, NICOLE M (PA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:BURGBACHER
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:PO BOX 713130
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45271-0001
Mailing Address - Country:US
Mailing Address - Phone:937-415-9100
Mailing Address - Fax:937-415-9191
Practice Address - Street 1:4160 LITTLE YORK RD
Practice Address - Street 2:SUITE 10
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45414-5800
Practice Address - Country:US
Practice Address - Phone:937-415-9100
Practice Address - Fax:937-415-9191
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50002158363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00822690OtherRR MCR
OHBUPA2340Medicare UPIN
OHP00822690OtherRR MCR
OHPA23403Medicare PIN