Provider Demographics
NPI:1134416399
Name:SHIRK, NICOLE M (PA-C)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:SHIRK
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 1:801 N STATE ST STE 200
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46140-1270
Mailing Address - Country:US
Mailing Address - Phone:317-477-6360
Mailing Address - Fax:317-477-6361
Practice Address - Street 1:801 N STATE ST STE 200
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:IN
Practice Address - Zip Code:46140-1270
Practice Address - Country:US
Practice Address - Phone:317-477-6360
Practice Address - Fax:317-477-6361
Is Sole Proprietor?:No
Enumeration Date:2011-07-07
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001278A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM400049885Medicare PIN