Provider Demographics
NPI:1932491305
Name:SMITH, NICOLE E (PA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:E
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:E
Other - Last Name:MANION
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6600 BRUCEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95823-4671
Mailing Address - Country:US
Mailing Address - Phone:828-250-2823
Mailing Address - Fax:828-250-2932
Practice Address - Street 1:6600 BRUCEVILLE RD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-4671
Practice Address - Country:US
Practice Address - Phone:980-253-3160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-04
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001004045363A00000X
KYTC012363A00000X
CAPA52546363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant