Provider Demographics
NPI:1104008093
Name:CHARLES, NICOLE J (PAC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:J
Last Name:CHARLES
Suffix:
Gender:F
Credentials:PAC
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Mailing Address - Street 1:4729 COUNTY ROAD 101
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55345-2634
Mailing Address - Country:US
Mailing Address - Phone:952-974-3200
Mailing Address - Fax:952-974-3201
Practice Address - Street 1:500 S MAPLE ST
Practice Address - Street 2:
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387-1752
Practice Address - Country:US
Practice Address - Phone:952-442-2191
Practice Address - Fax:952-974-3201
Is Sole Proprietor?:No
Enumeration Date:2007-12-03
Last Update Date:2021-03-23
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Provider Licenses
StateLicense IDTaxonomies
MN1081363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1081OtherMN REGISTRATION