Provider Demographics
NPI:1528797206
Name:BRUIN, NICOLE RENEE (PA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:RENEE
Last Name:BRUIN
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:PO BOX 3677
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03061-3677
Mailing Address - Country:US
Mailing Address - Phone:603-577-7900
Mailing Address - Fax:603-577-7972
Practice Address - Street 1:280 MAIN ST
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03060-2919
Practice Address - Country:US
Practice Address - Phone:603-577-3300
Practice Address - Fax:603-577-3398
Is Sole Proprietor?:No
Enumeration Date:2022-06-07
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1995363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant