Provider Demographics
NPI:1588138663
Name:ROTHENGASS, NICHOLLE C (PA-C)
Entity type:Individual
Prefix:
First Name:NICHOLLE
Middle Name:C
Last Name:ROTHENGASS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1029 PARK DR APT 27
Mailing Address - Street 2:
Mailing Address - City:INDIAN HARBOUR BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32937-3638
Mailing Address - Country:US
Mailing Address - Phone:813-786-2691
Mailing Address - Fax:
Practice Address - Street 1:2254 HIGHWAY A1A
Practice Address - Street 2:
Practice Address - City:INDIAN HARBOUR BEACH
Practice Address - State:FL
Practice Address - Zip Code:32937-4922
Practice Address - Country:US
Practice Address - Phone:813-786-2691
Practice Address - Fax:321-779-7425
Is Sole Proprietor?:No
Enumeration Date:2019-01-11
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9111908363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant