Provider Demographics
NPI:1053368720
Name:KIRK, NICOLE (PA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:KIRK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:OFFIT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1000 RIVER RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CONSHOHOCKEN
Mailing Address - State:PA
Mailing Address - Zip Code:19428-2439
Mailing Address - Country:US
Mailing Address - Phone:800-355-3818
Mailing Address - Fax:610-834-2862
Practice Address - Street 1:9000 FRANKLIN SQUARE DR
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21237-3901
Practice Address - Country:US
Practice Address - Phone:410-682-7046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0003142363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDM411Medicare ID - Type Unspecified