Provider Demographics
NPI:1528133097
Name:PRESTWIDGE, NICOLE-ANN MARIA (PA-C)
Entity type:Individual
Prefix:
First Name:NICOLE-ANN
Middle Name:MARIA
Last Name:PRESTWIDGE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:15490 SW 134TH PL
Mailing Address - Street 2:APT 502
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33177-8122
Mailing Address - Country:US
Mailing Address - Phone:305-971-4354
Mailing Address - Fax:305-971-4654
Practice Address - Street 1:11373 SW 211TH ST
Practice Address - Street 2:SUITE 16
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33189-2245
Practice Address - Country:US
Practice Address - Phone:305-234-0009
Practice Address - Fax:305-234-8688
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPA 9103079363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant