Provider Demographics
NPI:1952929887
Name:PABLO, NICOLE ANN
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANN
Last Name:PABLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:273 TELOMA DR
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-2139
Mailing Address - Country:US
Mailing Address - Phone:805-340-0972
Mailing Address - Fax:
Practice Address - Street 1:1700 N ROSE AVE STE 320
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93030-7648
Practice Address - Country:US
Practice Address - Phone:805-485-8709
Practice Address - Fax:805-485-5521
Is Sole Proprietor?:No
Enumeration Date:2020-07-07
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA58305363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical