Provider Demographics
NPI:1992791677
Name:GIRARD, NICOLE M (MD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:GIRARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1083 E 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84103-4101
Mailing Address - Country:US
Mailing Address - Phone:801-824-8826
Mailing Address - Fax:
Practice Address - Street 1:1083 E 1ST AVE
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84103-4101
Practice Address - Country:US
Practice Address - Phone:801-824-8826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3769361205208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q50369Medicare UPIN