Provider Demographics
NPI:1912556549
Name:SCHROEDER, NICOLE ALEXIS (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ALEXIS
Last Name:SCHROEDER
Suffix:
Gender:F
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 1:700 CHILDRENS DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43205-2664
Mailing Address - Country:US
Mailing Address - Phone:614-722-2000
Mailing Address - Fax:
Practice Address - Street 1:700 CHILDRENS DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-2664
Practice Address - Country:US
Practice Address - Phone:614-722-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-06
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
OH50.006503363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0436087Medicaid