Provider Demographics
NPI:1992177844
Name:CONWAY, NICOLE ELIZABETH (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:ELIZABETH
Last Name:CONWAY
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 1:11011 SHERIDAN ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33026-1505
Mailing Address - Country:US
Mailing Address - Phone:954-437-1500
Mailing Address - Fax:
Practice Address - Street 1:11011 SHERIDAN ST
Practice Address - Street 2:SUITE 302
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33026-1505
Practice Address - Country:US
Practice Address - Phone:954-437-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-30
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9109077363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant