MEDICARE: NICOLE ANNE MANTILLA PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1295341667
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE ANNE MANTILLA PA-C

Provider Business Mailing Address
First Line	:	7430 CORDOBA CIR APT 206
Second Line	:
City	:	LELAND
State	:	NC
Zip	:	28451-2540
Country	:	US
Telephone Number	:	607-244-2929
Fax Number	:

Provider Business Practice Location Address
First Line	:	2909 MARKET ST
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28403-1221
Country	:	US
Telephone Number	:	910-687-4888
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/21/2020
Last Update Date	:	03/17/2026

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