Provider Demographics
NPI:1831626761
Name:LANDIS, NICOLE L (PA-C)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:L
Last Name:LANDIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:L
Other - Last Name:RENZI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2580 HAYMAKER RD STE 102
Mailing Address - Street 2:
Mailing Address - City:MONROEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15146-3500
Mailing Address - Country:US
Mailing Address - Phone:412-858-3070
Mailing Address - Fax:
Practice Address - Street 1:2580 HAYMAKER RD STE 102
Practice Address - Street 2:
Practice Address - City:MONROEVILLE
Practice Address - State:PA
Practice Address - Zip Code:15146-3500
Practice Address - Country:US
Practice Address - Phone:412-858-3070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-23
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA059082363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
14034537OtherCAQH