Healthcare Provider Details

I. General information

NPI: 1700224292
Provider Name (Legal Business Name): NICCOLE READ CAMPBELL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2013
Last Update Date: 11/01/2022
Certification Date: 11/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18322 SONTERRA PL STE 107
SAN ANTONIO TX
78258-4196
US

IV. Provider business mailing address

123 MIRROR LK
SAN ANTONIO TX
78260-4351
US

V. Phone/Fax

Practice location:
  • Phone: 210-495-5771
  • Fax: 210-966-9106
Mailing address:
  • Phone: 210-488-1961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: