Provider Demographics
NPI:1760182372
Name:NIKOLIC, DEJAN (PA-C)
Entity Type:Individual
Prefix:
First Name:DEJAN
Middle Name:
Last Name:NIKOLIC
Suffix:
Gender:M
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 1:401 MULBERRY ST SW STE 102
Mailing Address - Street 2:
Mailing Address - City:LENOIR
Mailing Address - State:NC
Mailing Address - Zip Code:28645-5463
Mailing Address - Country:US
Mailing Address - Phone:182-875-7643
Mailing Address - Fax:
Practice Address - Street 1:401 MULBERRY ST SW STE 102
Practice Address - Street 2:
Practice Address - City:LENOIR
Practice Address - State:NC
Practice Address - Zip Code:28645-5463
Practice Address - Country:US
Practice Address - Phone:182-875-7643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-03
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NC0010-13100363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical