Basic Information
| Provider Information | |||||||||
| NPI: | 1124144787 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHOURY | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 960 JOHNSON FERRY ROAD | ||||||||
| Address2: | SUITE 200 ADVANCED ENT, PC | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4049430900 | ||||||||
| FaxNumber: | 4049431390 | ||||||||
| Practice Location | |||||||||
| Address1: | 960 JOHNSON FERRY ROAD | ||||||||
| Address2: | SUITE 200 ADVANCED ENT, PC | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4049430900 | ||||||||
| FaxNumber: | 4049431390 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2007 | ||||||||
| LastUpdateDate: | 05/26/2011 | ||||||||
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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 | 363AM0700X | 003041 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 97WCCMF | 01 | GA | CARRIER PROVIDER NUMBER | OTHER |