Healthcare Provider Details

I. General information

NPI: 1932491305
Provider Name (Legal Business Name): NICOLE E SMITH PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE E MANION

II. Dates (important events)

Enumeration Date: 05/04/2011
Last Update Date: 01/11/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6600 BRUCEVILLE RD
SACRAMENTO CA
95823-4671
US

IV. Provider business mailing address

6600 BRUCEVILLE RD
SACRAMENTO CA
95823-4671
US

V. Phone/Fax

Practice location:
  • Phone: 980-253-3160
  • Fax:
Mailing address:
  • Phone: 828-250-2823
  • Fax: 828-250-2932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number001004045
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberTC012
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA52546
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: