Healthcare Provider Details

I. General information

NPI: 1487926416
Provider Name (Legal Business Name): NICOLE M MCCANN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2012
Last Update Date: 05/23/2022
Certification Date: 05/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13005 US HIGHWAY 301 S
RIVERVIEW FL
33578-7439
US

IV. Provider business mailing address

5380 PRIMROSE LAKE CIR
TAMPA FL
33647-3589
US

V. Phone/Fax

Practice location:
  • Phone: 813-915-5291
  • Fax: 813-915-5293
Mailing address:
  • Phone: 813-769-2778
  • Fax: 813-769-2779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: