Provider Demographics
NPI:1902129521
Name:WETHERHOLT, NICOLE AMY (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:AMY
Last Name:WETHERHOLT
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 1:1259 BERYLSTONE DR
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92545-2183
Mailing Address - Country:US
Mailing Address - Phone:951-487-1713
Mailing Address - Fax:
Practice Address - Street 1:6601 WHITE FEATHER RD
Practice Address - Street 2:
Practice Address - City:JOSHUA TREE
Practice Address - State:CA
Practice Address - Zip Code:92252-6607
Practice Address - Country:US
Practice Address - Phone:760-366-3711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-10
Last Update Date:2013-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA20731363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant