Provider Demographics
NPI:1992002190
Name:PAYNE, NICOLE BRADLEY (PA-C)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:BRADLEY
Last Name:PAYNE
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:PO BOX 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:336-718-6199
Mailing Address - Fax:336-719-6190
Practice Address - Street 1:2025 FRONTIS PLAZA BLVD STE 100
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-5663
Practice Address - Country:US
Practice Address - Phone:336-718-6199
Practice Address - Fax:336-719-6190
Is Sole Proprietor?:No
Enumeration Date:2011-02-24
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-02825363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1992002190Medicaid
SC1967PAMedicaid
NCNCA737BMedicare PIN
SC1967PAMedicaid