Provider Demographics
NPI:1366078065
Name:ALBERTSON, NICOLE CARRIE (PA-C)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:CARRIE
Last Name:ALBERTSON
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 1:2920 TELEGRAPH AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-2031
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13365 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-9023
Practice Address - Country:US
Practice Address - Phone:310-504-1825
Practice Address - Fax:888-972-1912
Is Sole Proprietor?:No
Enumeration Date:2020-03-13
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPA031753363A00000X
VA0110-007125363A00000X
CA10000363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant