Provider Demographics
NPI:1780763524
Name:NICHOLSON, JANICE (PA-C)
Entity type:Individual
Prefix:
First Name:JANICE
Middle Name:
Last Name:NICHOLSON
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 1:3762 DURHAM RD STE A
Mailing Address - Street 2:
Mailing Address - City:ROXBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27573-2741
Mailing Address - Country:US
Mailing Address - Phone:336-330-0400
Mailing Address - Fax:336-330-0031
Practice Address - Street 1:3762 DURHAM RD STE A
Practice Address - Street 2:
Practice Address - City:ROXBORO
Practice Address - State:NC
Practice Address - Zip Code:27573-2741
Practice Address - Country:US
Practice Address - Phone:336-330-0400
Practice Address - Fax:336-330-0031
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA-442207P00000X
NC101575363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1780763524Medicaid
MER96254Medicare UPIN
NC1780763524Medicaid