Healthcare Provider Details

I. General information

NPI: 1912955352
Provider Name (Legal Business Name): NICOLE A MORTIER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

332 N LAUDERDALE ST
MEMPHIS TN
38105-2794
US

IV. Provider business mailing address

332 N LAUDERDALE ST
MEMPHIS TN
38105-2794
US

V. Phone/Fax

Practice location:
  • Phone: 901-495-3006
  • Fax: 901-495-3842
Mailing address:
  • Phone: 901-495-3006
  • Fax: 901-495-3842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1173
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: