Provider Demographics
NPI:1194105221
Name:COOLIDGE, NICK (PA-C)
Entity type:Individual
Prefix:
First Name:NICK
Middle Name:
Last Name:COOLIDGE
Suffix:
Gender:M
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 1:6039 WILLOMERE CIR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27107-3731
Mailing Address - Country:US
Mailing Address - Phone:517-231-0439
Mailing Address - Fax:
Practice Address - Street 1:1140 E MICHIGAN AVE STE 200
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-1806
Practice Address - Country:US
Practice Address - Phone:517-364-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-03
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-09447208VP0000X, 208VP0000X
MI5315244432363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical