Provider Demographics
NPI:1770672172
Name:MCGOVERN, NIKKI-ANN GILIAM (PA-C)
Entity Type:Individual
Prefix:
First Name:NIKKI-ANN
Middle Name:GILIAM
Last Name:MCGOVERN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NIKKI
Other - Middle Name:ANN
Other - Last Name:GILIAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2415 N ORANGE AVE STE 302
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-5505
Mailing Address - Country:US
Mailing Address - Phone:407-303-7250
Mailing Address - Fax:407-303-7255
Practice Address - Street 1:2415 N ORANGE AVE STE 302
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-5505
Practice Address - Country:US
Practice Address - Phone:407-303-7250
Practice Address - Fax:407-303-7255
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103180363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant