Provider Demographics
NPI:1710410600
Name:RICKABAUGH, NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:RICKABAUGH
Suffix:
Gender:F
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 1:310 13TH ST SE
Mailing Address - Street 2:APT 2
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20003-2268
Mailing Address - Country:US
Mailing Address - Phone:540-931-6569
Mailing Address - Fax:
Practice Address - Street 1:310 13TH ST SE
Practice Address - Street 2:APT 2
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20003-2268
Practice Address - Country:US
Practice Address - Phone:540-931-6569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-06
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110-005726363A00000X
DCPA031345363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant