Healthcare Provider Details

I. General information

NPI: 1447798111
Provider Name (Legal Business Name): NICOLE KLOPOVIC PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2017
Last Update Date: 02/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9045 BRUCEVILLE RD STE 100
ELK GROVE CA
95758-5950
US

IV. Provider business mailing address

PO BOX 580823
ELK GROVE CA
95758-0014
US

V. Phone/Fax

Practice location:
  • Phone: 916-479-9110
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number54175
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: