Provider Demographics
NPI:1427310614
Name:WELK, NIKKI LEA (PA-C)
Entity type:Individual
Prefix:MRS
First Name:NIKKI
Middle Name:LEA
Last Name:WELK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NIKKI
Other - Middle Name:
Other - Last Name:WOLD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3173 43RD STREET S STE A
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-4564
Mailing Address - Country:US
Mailing Address - Phone:701-478-8780
Mailing Address - Fax:701-478-8781
Practice Address - Street 1:3173 43RD STREET S STE A
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-4564
Practice Address - Country:US
Practice Address - Phone:701-478-8780
Practice Address - Fax:701-478-8781
Is Sole Proprietor?:No
Enumeration Date:2012-06-13
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0483363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND71049Medicaid
ND71049Medicaid