Provider Demographics
NPI:1154422632
Name:NICKELL, DEBRA F (PA-C)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:F
Last Name:NICKELL
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 1:3061 FIELDSTONE WAY
Mailing Address - Street 2:SUITE 700
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40513-1718
Mailing Address - Country:US
Mailing Address - Phone:859-296-9900
Mailing Address - Fax:859-296-9603
Practice Address - Street 1:3061 FIELDSTONE WAY
Practice Address - Street 2:SUITE 700
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40513-1718
Practice Address - Country:US
Practice Address - Phone:859-296-9900
Practice Address - Fax:859-296-9603
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA400363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95004008Medicaid
KY37903705OtherMEDICAID LAB GROUP
CB5773OtherRR MEDICARE GROUP
KY4000501OtherMEDICARE LAB GROUP
CB5773OtherRR MEDICARE GROUP
KY95004008Medicaid
KY0623722Medicare ID - Type Unspecified