Provider Demographics
NPI:1124144787
Name:KHOURY, NICOLE LEE (PA-C)
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:LEE
Last Name:KHOURY
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 1:960 JOHNSON FERRY ROAD
Mailing Address - Street 2:SUITE 200 ADVANCED ENT, PC
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342
Mailing Address - Country:US
Mailing Address - Phone:404-943-0900
Mailing Address - Fax:404-943-1390
Practice Address - Street 1:960 JOHNSON FERRY ROAD
Practice Address - Street 2:SUITE 200 ADVANCED ENT, PC
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342
Practice Address - Country:US
Practice Address - Phone:404-943-0900
Practice Address - Fax:404-943-1390
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003041363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA97WCCMFOtherCARRIER PROVIDER NUMBER
GAP51010Medicare UPIN
GAGPR861Medicare ID - Type UnspecifiedGROUP PROVIDER NUMBER