Provider Demographics
NPI:1720610132
Name:ROYER, NICOLE M (PA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:ROYER
Suffix:
Gender:F
Credentials:PA
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:224-D CORNWALL ST., NW
Mailing Address - Street 2:SUITE 403
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-2704
Mailing Address - Country:US
Mailing Address - Phone:703-737-6010
Mailing Address - Fax:703-443-8643
Practice Address - Street 1:19450 DEERFIELD AVENUE, SUITE 325
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-8503
Practice Address - Country:US
Practice Address - Phone:571-252-8119
Practice Address - Fax:800-735-1643
Is Sole Proprietor?:No
Enumeration Date:2020-02-04
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0110-007675363A00000X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA30017582100001Medicaid
VA1720610132Medicaid