Provider Demographics
NPI:1538632187
Name:NICKSON, LAUREN A (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:A
Last Name:NICKSON
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1206 BROWN ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27889-4671
Mailing Address - Country:US
Mailing Address - Phone:252-946-4134
Mailing Address - Fax:252-946-2432
Practice Address - Street 1:1206 BROWN ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NC
Practice Address - Zip Code:27889-4671
Practice Address - Country:US
Practice Address - Phone:252-946-4134
Practice Address - Fax:252-946-2432
Is Sole Proprietor?:No
Enumeration Date:2019-01-07
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-08710363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant