Provider Demographics
NPI:1699335026
Name:HALL, NICOLE SUE (PA-C)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:SUE
Last Name:HALL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 KENTUCKY ST
Mailing Address - Street 2:P.O. BOX 924
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-8202
Mailing Address - Country:US
Mailing Address - Phone:707-712-9000
Mailing Address - Fax:
Practice Address - Street 1:8110 TIMBERLAKE WAY
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-5401
Practice Address - Country:US
Practice Address - Phone:916-689-4111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-18
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56323363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant