Provider Demographics
NPI:1295995462
Name:WALTZ, NICHOLE ANN (PA)
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:ANN
Last Name:WALTZ
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:416 E 36TH ST
Practice Address - Street 2:STE 200
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-1030
Practice Address - Country:US
Practice Address - Phone:980-302-9800
Practice Address - Fax:980-302-9810
Is Sole Proprietor?:No
Enumeration Date:2008-06-11
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-01323363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1295995462Medicaid
SC2603PAMedicaid
TX75-2616977-118OtherTRICARE
TX8108NKOtherBCBS
TX338925601Medicaid
NC8101840Medicaid
NC1295995462Medicaid
NCNCS474AMedicare PIN
NC2759209Medicare PIN