Basic Information
| Provider Information | |||||||||
| NPI: | 1053707810 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HANGSTERFER | ||||||||
| FirstName: | NICOLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5717 PACIFIC CENTER BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921214250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8588591188 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5717 PACIFIC CENTER BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921214250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8588591188 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2015 | ||||||||
| LastUpdateDate: | 05/06/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363AM0700X | PA55858 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 085.005922 | 01 | IL | PHYSICIAN ASSISTANT LICENSE | OTHER |