Provider Demographics
NPI:1194918771
Name:NICOL, KRISTI LYNN (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTI
Middle Name:LYNN
Last Name:NICOL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 601692
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1692
Mailing Address - Country:US
Mailing Address - Phone:704-512-6240
Mailing Address - Fax:704-512-6241
Practice Address - Street 1:4525 CAMERON VALLEY PKWY
Practice Address - Street 2:SUITE 1500
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-3546
Practice Address - Country:US
Practice Address - Phone:704-512-6240
Practice Address - Fax:704-512-6241
Is Sole Proprietor?:No
Enumeration Date:2007-08-27
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-00999363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2771276BMedicare PIN
NC2771276AMedicare PIN