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General NPI Number Information
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NPI Number | 1134604978
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Entity Type | Individual
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Provider Name | NIKI MANOLE NINOPOULOS PA-C
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Gender | Female
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Dates
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Enumeration Date | 09/27/2018
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Last Update Date | 12/17/2018
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Provider Practice Location Address
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Address Line | 3901 CARLISLE BLVD NE
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City | ALBUQUERQUE
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State | NM
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Zip | 87107-4503
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Country | US
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Telephone | 505-254-6100
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Fax | 505-546-5322
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Provider Business Mailing Address
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Address Line | 4501 LARCHMONT DR NE
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City | ALBUQUERQUE
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State | NM
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Zip | 87111-3042
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Country | US
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Telephone | 505-315-6932
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | PA2018-0074
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number |
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License Number State | NM
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Taxonomy #3
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA2018-0074
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License Number State | NM
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