Provider Demographics
NPI:1811087901
Name:WISSING, NICOLE DIANE (PA-C)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:DIANE
Last Name:WISSING
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:DIANE
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1430 MEDICAL CENTER PKWY
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37129-2202
Mailing Address - Country:US
Mailing Address - Phone:615-893-4480
Mailing Address - Fax:615-895-6212
Practice Address - Street 1:1430 MEDICAL CENTER PKWY
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37129-2202
Practice Address - Country:US
Practice Address - Phone:615-893-4480
Practice Address - Fax:615-895-6212
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2039363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO804796Medicare ID - Type Unspecified
COQ64906Medicare UPIN