Provider Demographics
NPI:1548521420
Name:SHERRY, NICOLE LYNN (PA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNN
Last Name:SHERRY
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 1:6560 FANNIN ST
Mailing Address - Street 2:SUITE 2200
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2761
Mailing Address - Country:US
Mailing Address - Phone:713-441-6102
Mailing Address - Fax:
Practice Address - Street 1:6560 FANNIN ST
Practice Address - Street 2:SUITE 2200
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2761
Practice Address - Country:US
Practice Address - Phone:713-441-6102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-06
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA08837363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03585013Medicaid
NYJ400073022Medicare PIN