Provider Demographics
NPI:1679809008
Name:FALDMO, NICOLE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:
Last Name:FALDMO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1688 E BOSTON ST STE 101
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-6222
Mailing Address - Country:US
Mailing Address - Phone:480-855-0085
Mailing Address - Fax:480-855-0086
Practice Address - Street 1:1688 E BOSTON ST STE 101
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-6222
Practice Address - Country:US
Practice Address - Phone:480-855-0085
Practice Address - Fax:480-855-0086
Is Sole Proprietor?:No
Enumeration Date:2009-10-20
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013656363A00000X
AZ6548363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ253585OtherUPIN