Provider Demographics
NPI:1649472358
Name:STROUP, NICOLE C (PA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:C
Last Name:STROUP
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 1:170 TRYENS DR
Mailing Address - Street 2:
Mailing Address - City:MAYS LANDING
Mailing Address - State:NJ
Mailing Address - Zip Code:08330-4910
Mailing Address - Country:US
Mailing Address - Phone:609-407-4939
Mailing Address - Fax:
Practice Address - Street 1:222 NEW RD
Practice Address - Street 2:
Practice Address - City:LINWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08221-1299
Practice Address - Country:US
Practice Address - Phone:609-653-6676
Practice Address - Fax:609-653-8828
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00104400363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant