Provider Demographics
NPI:1255368155
Name:NICHOLS, KRISTINA ELIZABETH (PA)
Entity type:Individual
Prefix:MRS
First Name:KRISTINA
Middle Name:ELIZABETH
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:KRISTINA
Other - Middle Name:ELIZABETH
Other - Last Name:HOHAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 601643
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1643
Mailing Address - Country:US
Mailing Address - Phone:704-355-0720
Mailing Address - Fax:704-355-5948
Practice Address - Street 1:1000 BLYTHE BLVD
Practice Address - Street 2:CMC ANNEX 1ST FLOOR
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5812
Practice Address - Country:US
Practice Address - Phone:704-355-0720
Practice Address - Fax:704-355-5948
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-00886363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1071PAMedicaid
NC1255368155Medicaid
NC8102218Medicaid
SC1071PAMedicaid