Provider Demographics
NPI:1063989689
Name:OTAHAL, NIKOLE R (PA-C)
Entity type:Individual
Prefix:
First Name:NIKOLE
Middle Name:R
Last Name:OTAHAL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 COUNTY ROAD 3101
Mailing Address - Street 2:
Mailing Address - City:ORANGE GROVE
Mailing Address - State:TX
Mailing Address - Zip Code:78372-9681
Mailing Address - Country:US
Mailing Address - Phone:210-835-8451
Mailing Address - Fax:
Practice Address - Street 1:5917 CROSSTOWN EXPRESSWAY SH 286
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78417
Practice Address - Country:US
Practice Address - Phone:361-854-0811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-01
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA12349363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant