Provider Demographics
NPI:1811983174
Name:NICHOLAS, AMY L (PA)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:NICHOLAS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:L
Other - Last Name:HICKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:3139 SOUTHLAKE PARK RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-2501
Mailing Address - Country:US
Mailing Address - Phone:214-668-6575
Mailing Address - Fax:
Practice Address - Street 1:1650 W NORTHWEST HWY STE 200
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-8122
Practice Address - Country:US
Practice Address - Phone:972-716-3922
Practice Address - Fax:214-948-5516
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03950363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8C9740Medicare PIN
TXQ32663Medicare UPIN