Provider Demographics
NPI:1134672116
Name:BACK, NICOLE E (PA-C)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:E
Last Name:BACK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:E
Other - Last Name:GENTRY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:675 N SAINT CLAIR ST STE 21-100
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-5970
Mailing Address - Country:US
Mailing Address - Phone:312-695-0990
Mailing Address - Fax:312-695-1106
Practice Address - Street 1:675 N SAINT CLAIR ST STE 21-100
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-5970
Practice Address - Country:US
Practice Address - Phone:312-695-0990
Practice Address - Fax:312-695-1106
Is Sole Proprietor?:No
Enumeration Date:2016-07-26
Last Update Date:2025-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085005861363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant