Provider Demographics
NPI:1740580588
Name:WOOD, NICOLE DEANNA (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:DEANNA
Last Name:WOOD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:DEANNA
Other - Last Name:CASCONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:33523 8 MILE RD STE M2
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-4119
Mailing Address - Country:US
Mailing Address - Phone:248-824-2675
Mailing Address - Fax:248-824-2676
Practice Address - Street 1:33523 8 MILE RD STE M2
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-4119
Practice Address - Country:US
Practice Address - Phone:248-824-2675
Practice Address - Fax:248-824-2676
Is Sole Proprietor?:No
Enumeration Date:2010-10-27
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005875363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant