Provider Demographics
NPI:1245355049
Name:ANDERSON, NICOLE (PA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 W ICE LAKE RD
Mailing Address - Street 2:
Mailing Address - City:IRON RIVER
Mailing Address - State:MI
Mailing Address - Zip Code:49935-9526
Mailing Address - Country:US
Mailing Address - Phone:906-265-6141
Mailing Address - Fax:906-265-2033
Practice Address - Street 1:1400 W ICE LAKE RD
Practice Address - Street 2:
Practice Address - City:IRON RIVER
Practice Address - State:MI
Practice Address - Zip Code:49935-9526
Practice Address - Country:US
Practice Address - Phone:906-265-6121
Practice Address - Fax:906-265-2033
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003919363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41951600Medicaid
MI700C610000OtherBCBS-MI
MI700C610000OtherBCBS-MI
P71866Medicare UPIN
P33590007Medicare PIN
MIM31750033Medicare PIN