Provider Demographics
NPI:1104143924
Name:HERRICK, NICOLE M (PA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:HERRICK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:N
Other - Last Name:MAZZEO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:315 N SAN SABA STE 1135
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78207-3255
Mailing Address - Country:US
Mailing Address - Phone:210-704-8878
Mailing Address - Fax:
Practice Address - Street 1:333 N SANTA ROSA
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-3108
Practice Address - Country:US
Practice Address - Phone:210-704-4199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-04
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA059660363A00000X
TXPA14138363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant