Provider Demographics
NPI:1780860908
Name:DWYER, NICOLE M (PA)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:M
Last Name:DWYER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:NICOLE
Other - Middle Name:M
Other - Last Name:DWYER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MPAS, PA-C, LMP
Mailing Address - Street 1:PO BOX 8007
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-0507
Mailing Address - Country:US
Mailing Address - Phone:208-882-4511
Mailing Address - Fax:
Practice Address - Street 1:2500 W A ST STE 101
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-6000
Practice Address - Country:US
Practice Address - Phone:208-882-0540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-17
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
IDPA-1980363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPA60101731OtherWASHINGTON STATE LICENSE