Provider Demographics
NPI:1134604978
Name:NINOPOULOS, NIKI MANOLE (PA-C)
Entity type:Individual
Prefix:
First Name:NIKI
Middle Name:MANOLE
Last Name:NINOPOULOS
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 1:4501 LARCHMONT DR NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-3042
Mailing Address - Country:US
Mailing Address - Phone:505-315-6932
Mailing Address - Fax:
Practice Address - Street 1:3901 CARLISLE BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-4503
Practice Address - Country:US
Practice Address - Phone:505-254-6100
Practice Address - Fax:505-546-5322
Is Sole Proprietor?:No
Enumeration Date:2018-09-27
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2018-0074207N00000X, 363AM0700X
NM363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207N00000XAllopathic & Osteopathic PhysiciansDermatology