Provider Demographics
NPI:1437327079
Name:NICHOLSON, SANDRA L (PA-C)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:L
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:L
Other - Last Name:KLINGENSMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:121 DOCTORS LN
Mailing Address - Street 2:
Mailing Address - City:CLARION
Mailing Address - State:PA
Mailing Address - Zip Code:16214-8515
Mailing Address - Country:US
Mailing Address - Phone:814-226-3470
Mailing Address - Fax:814-226-3479
Practice Address - Street 1:367 ROUTE 28
Practice Address - Street 2:
Practice Address - City:BROOKVILLE
Practice Address - State:PA
Practice Address - Zip Code:15825-7161
Practice Address - Country:US
Practice Address - Phone:814-849-0833
Practice Address - Fax:814-849-1288
Is Sole Proprietor?:No
Enumeration Date:2008-02-18
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA002412363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103275090 0001Medicaid
PA172719R4WMedicare PIN