Basic Information
| Provider Information | |||||||||
| NPI: | 1790099547 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NUCKOLS | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1920 CORPORATE DR STE 208 | ||||||||
| Address2: | |||||||||
| City: | SAN MARCOS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786666286 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5128786330 | ||||||||
| FaxNumber: | 5128786941 | ||||||||
| Practice Location | |||||||||
| Address1: | 1920 CORPORATE DR STE 208 | ||||||||
| Address2: | |||||||||
| City: | SAN MARCOS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786666286 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5128786330 | ||||||||
| FaxNumber: | 8708786941 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2010 | ||||||||
| LastUpdateDate: | 07/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA 05907 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | P02144922 | 01 | RR MEDICARE | OTHER | 679419 | 01 | MEDICARE | OTHER | 370968503 | 05 | TX | MEDICAID |