Provider Demographics
NPI:1447448097
Name:FERSCHKE, NICOLE LYNN (PA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNN
Last Name:FERSCHKE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1138 N ALMA SCHOOL RD STE 120
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-3003
Mailing Address - Country:US
Mailing Address - Phone:888-306-5315
Mailing Address - Fax:
Practice Address - Street 1:1138 N ALMA SCHOOL RD
Practice Address - Street 2:STE 120
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-3002
Practice Address - Country:US
Practice Address - Phone:623-293-0343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3684363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ535401Medicaid
AZZ141166Medicare PIN
AZ535401Medicaid