Healthcare Provider Details

I. General information

NPI: 1598288185
Provider Name (Legal Business Name): NICOLE MARIE WURSTLE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 S TRIMBLE RD BLDG C
MANSFIELD OH
44907-2200
US

IV. Provider business mailing address

1221 S TRIMBLE RD BLDG C
MANSFIELD OH
44907-2200
US

V. Phone/Fax

Practice location:
  • Phone: 614-664-3595
  • Fax:
Mailing address:
  • Phone: 614-664-3595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.005159RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: