Provider Demographics
NPI:1366626954
Name:ATALLAH, NICOLE M (PA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:ATALLAH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9550 E THUNDERBIRD RD UNIT 266
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-3775
Mailing Address - Country:US
Mailing Address - Phone:612-239-5228
Mailing Address - Fax:
Practice Address - Street 1:9550 E THUNDERBIRD RD UNIT 266
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-3775
Practice Address - Country:US
Practice Address - Phone:612-239-5228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-19
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPA030517207T00000X
AZ4555363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery