Provider Demographics
NPI:1124616271
Name:LUJAN, NICOLETTE
Entity type:Individual
Prefix:
First Name:NICOLETTE
Middle Name:
Last Name:LUJAN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71511 HIGHWAY 111 STE H
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-4465
Mailing Address - Country:US
Mailing Address - Phone:760-773-2200
Mailing Address - Fax:
Practice Address - Street 1:71511 HIGHWAY 111 STE H
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-4465
Practice Address - Country:US
Practice Address - Phone:760-773-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-05
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59404363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant