Provider Demographics
NPI:1740204171
Name:ROSS, NICOLE EVANS (MD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:EVANS
Last Name:ROSS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1075
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30015-1075
Mailing Address - Country:US
Mailing Address - Phone:678-671-6228
Mailing Address - Fax:678-935-3343
Practice Address - Street 1:2131 PACE ST
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-6652
Practice Address - Country:US
Practice Address - Phone:678-671-6228
Practice Address - Fax:678-935-3343
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA043038207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine