Healthcare Provider Details

I. General information

NPI: 1487052130
Provider Name (Legal Business Name): NICOLE SURMAN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2014
Last Update Date: 06/11/2025
Certification Date: 06/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13995 W STATLER BLVD STE 150
SURPRISE AZ
85374-5512
US

IV. Provider business mailing address

13995 W STATLER BLVD STE 150
SURPRISE AZ
85374-5512
US

V. Phone/Fax

Practice location:
  • Phone: 805-560-4464
  • Fax:
Mailing address:
  • Phone: 480-556-0446
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number003678
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number11106
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: