Provider Demographics
NPI:1104282755
Name:SHOWALTER, NICOLE M (PA-C)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:SHOWALTER
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 1:620 IRIS DR
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:CO
Mailing Address - Zip Code:80751-4716
Mailing Address - Country:US
Mailing Address - Phone:970-522-7266
Mailing Address - Fax:970-522-4258
Practice Address - Street 1:620 IRIS DR
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:CO
Practice Address - Zip Code:80751-4716
Practice Address - Country:US
Practice Address - Phone:970-522-7266
Practice Address - Fax:970-522-4258
Is Sole Proprietor?:No
Enumeration Date:2016-01-12
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
COPA.0004571OtherCOLORADO STATE LICENSE
COPA.0004571OtherCOLORADO STATE LICENSE