Provider Demographics
NPI:1194801001
Name:TIMMONS, NIKOL DEEM (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:MRS
First Name:NIKOL
Middle Name:DEEM
Last Name:TIMMONS
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816 GREENBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-6952
Mailing Address - Country:US
Mailing Address - Phone:704-293-6721
Mailing Address - Fax:
Practice Address - Street 1:1207 CREWS RD STE E
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-7582
Practice Address - Country:US
Practice Address - Phone:704-841-8162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101627363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8101457Medicaid
NC70056PMedicare UPIN