Healthcare Provider Details

I. General information

NPI: 1982726378
Provider Name (Legal Business Name): NICOLE MARIE FARWELL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 07/20/2024
Certification Date: 07/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13052 NEWPORT AVE
TUSTIN CA
92780-3535
US

IV. Provider business mailing address

13052 NEWPORT AVE
TUSTIN CA
92780-3535
US

V. Phone/Fax

Practice location:
  • Phone: 888-227-3312
  • Fax:
Mailing address:
  • Phone: 888-227-3312
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA18690
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: