Provider Demographics
NPI:1861827966
Name:WOLTJEN, NICHOLAS T (PA-C)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:T
Last Name:WOLTJEN
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 1:5070 A1A
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32963-1400
Mailing Address - Country:US
Mailing Address - Phone:772-234-3700
Mailing Address - Fax:
Practice Address - Street 1:5070 A1A
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32963
Practice Address - Country:US
Practice Address - Phone:772-234-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-08
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA056346363AM0700X
FLPA9110372363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical