Provider Demographics
NPI:1629880588
Name:PTAK, NICOLE FAY
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:FAY
Last Name:PTAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3512 TABORA DR
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94509-5438
Mailing Address - Country:US
Mailing Address - Phone:408-702-0083
Mailing Address - Fax:
Practice Address - Street 1:3720 SUNSET LN STE D
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-6124
Practice Address - Country:US
Practice Address - Phone:925-978-0208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-27
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program