Provider Demographics
NPI:1982833232
Name:NICHOLSON, JOANNA CAMILLE (PA-C)
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:CAMILLE
Last Name:NICHOLSON
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:PO BOX 12060
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89112-0060
Mailing Address - Country:US
Mailing Address - Phone:702-360-2100
Mailing Address - Fax:909-557-1924
Practice Address - Street 1:9339 GENESEE AVE
Practice Address - Street 2:PLAZA 39
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-2119
Practice Address - Country:US
Practice Address - Phone:858-455-7557
Practice Address - Fax:858-455-1287
Is Sole Proprietor?:No
Enumeration Date:2009-07-08
Last Update Date:2011-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16008363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACQ242ZMedicare PIN