Provider Demographics
NPI:1962915967
Name:PANGBORN, NICOLE RAE (PA-C)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:RAE
Last Name:PANGBORN
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 1:95 SOLDIERS PASS RD STE B2
Mailing Address - Street 2:
Mailing Address - City:SEDONA
Mailing Address - State:AZ
Mailing Address - Zip Code:86336-4781
Mailing Address - Country:US
Mailing Address - Phone:928-203-4844
Mailing Address - Fax:928-203-4497
Practice Address - Street 1:95 SOLDIERS PASS RD STE B2
Practice Address - Street 2:
Practice Address - City:SEDONA
Practice Address - State:AZ
Practice Address - Zip Code:86336-4781
Practice Address - Country:US
Practice Address - Phone:928-203-4844
Practice Address - Fax:928-203-4497
Is Sole Proprietor?:No
Enumeration Date:2017-11-13
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6944363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical