Basic Information
| Provider Information | |||||||||
| NPI: | 1720590284 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLEMENTS | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | WHITMAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SEEGER | ||||||||
| OtherFirstName: | NICOLE | ||||||||
| OtherMiddleName: | WHITMAN | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 933 BRADBURY DR SE STE 2222 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871064375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052723120 | ||||||||
| FaxNumber: | 5052728060 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 UNSER BLVD NW | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059254126 | ||||||||
| FaxNumber: | 5059254721 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2017 | ||||||||
| LastUpdateDate: | 02/13/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA2019-0003 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | TEMPORARY | 01 | TX | TEXAS PHYSICIAN ASSISTANT BOARD | OTHER |