Provider Demographics
NPI:1770966384
Name:DOUSSAN, NICHOLE ANN TAYEH (PA-C)
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:ANN TAYEH
Last Name:DOUSSAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5514 OLYMPIAD DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77041-5519
Mailing Address - Country:US
Mailing Address - Phone:214-538-5435
Mailing Address - Fax:
Practice Address - Street 1:17200 ST LUKES WAY
Practice Address - Street 2:
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77384-8007
Practice Address - Country:US
Practice Address - Phone:936-266-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-30
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.200836363A00000X
TXPA12941363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05028232Medicaid
LA2400134Medicaid
LA2400134Medicaid