Provider Demographics
NPI:1720590284
Name:CLEMENTS, NICOLE WHITMAN (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:WHITMAN
Last Name:CLEMENTS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:WHITMAN
Other - Last Name:SEEGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:933 BRADBURY DR SE STE 2222
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4375
Mailing Address - Country:US
Mailing Address - Phone:505-272-3120
Mailing Address - Fax:505-272-8060
Practice Address - Street 1:301 UNSER BLVD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87121
Practice Address - Country:US
Practice Address - Phone:505-925-4126
Practice Address - Fax:505-925-4721
Is Sole Proprietor?:No
Enumeration Date:2017-10-24
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363A00000X
NMPA2019-0003363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTEMPORARYOtherTEXAS PHYSICIAN ASSISTANT BOARD