Provider Demographics
NPI:1316455850
Name:AVILEZ, NICOLE E (PA-C)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:E
Last Name:AVILEZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:E
Other - Last Name:WAUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1318 KANSAS DR
Mailing Address - Street 2:
Mailing Address - City:PAOLA
Mailing Address - State:KS
Mailing Address - Zip Code:66071-2107
Mailing Address - Country:US
Mailing Address - Phone:913-557-5678
Mailing Address - Fax:913-557-5681
Practice Address - Street 1:1318 KANSAS DR
Practice Address - Street 2:
Practice Address - City:PAOLA
Practice Address - State:KS
Practice Address - Zip Code:66071-2107
Practice Address - Country:US
Practice Address - Phone:913-557-5678
Practice Address - Fax:913-557-5681
Is Sole Proprietor?:No
Enumeration Date:2018-01-18
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2834363A00000X
KS15-02608363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant