Provider Demographics
NPI:1063516748
Name:SMITH, NICHOLE L (PA)
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:L
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:505 S 336TH ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-5947
Mailing Address - Country:US
Mailing Address - Phone:253-838-6180
Mailing Address - Fax:253-838-6285
Practice Address - Street 1:505 S 336TH ST
Practice Address - Street 2:SUITE 600
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-5947
Practice Address - Country:US
Practice Address - Phone:253-838-6180
Practice Address - Fax:253-838-6285
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2012-11-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI004867363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN88100028Medicare PIN
MIC37626060Medicare PIN