Provider Demographics
NPI:1124313366
Name:WOOTEN, NICOLE K (PA-C)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:K
Last Name:WOOTEN
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:PO BOX 83819
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20883-3819
Mailing Address - Country:US
Mailing Address - Phone:301-754-7991
Mailing Address - Fax:301-754-7990
Practice Address - Street 1:1500 FOREST GLEN RD
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-1483
Practice Address - Country:US
Practice Address - Phone:301-754-7991
Practice Address - Fax:301-754-7990
Is Sole Proprietor?:No
Enumeration Date:2011-06-16
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDC0004435363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical