Healthcare Provider Details

I. General information

NPI: 1023205903
Provider Name (Legal Business Name): NICOLE MICHELLE RINCON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NICOLE MICHELLE RINCON PA-C

II. Dates (important events)

Enumeration Date: 09/25/2007
Last Update Date: 08/01/2024
Certification Date: 08/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18880 CHERRY VALLEY BLVD
TUOLUMNE CA
95379-9506
US

IV. Provider business mailing address

18880 CHERRY VALLEY BLVD
TUOLUMNE CA
95379-9506
US

V. Phone/Fax

Practice location:
  • Phone: 909-732-2570
  • Fax:
Mailing address:
  • Phone: 909-732-2570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA19355
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: