Provider Demographics
NPI:1386702652
Name:NICHOLSON, PATRICIA ANN (PA)
Entity type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:ANN
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2101 E JEFFERSON ST
Mailing Address - Street 2:KAISER PERMANENTE MEDICARE ENROLLMENT
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-2424
Mailing Address - Fax:
Practice Address - Street 1:224B CORNWALL ST NW
Practice Address - Street 2:LOUDOUN FREE CLINIC
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-2701
Practice Address - Country:US
Practice Address - Phone:703-779-5416
Practice Address - Fax:703-779-5407
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC01483363A00000X
VA0110001790363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
011682K92Medicare ID - Type Unspecified
P89643Medicare UPIN