Provider Demographics
NPI:1902991458
Name:WINBUSH, NICOLE YVETTE (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:YVETTE
Last Name:WINBUSH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 E ELLERBEE ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-4228
Mailing Address - Country:US
Mailing Address - Phone:415-529-8592
Mailing Address - Fax:
Practice Address - Street 1:106 E ELLERBEE ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-4228
Practice Address - Country:US
Practice Address - Phone:415-529-8592
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA88691207Q00000X
NC312299207Q00000X
CAA78596207Q00000X
MN48415207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2436123OtherARAZ
MN01-23535OtherMEDICA - CHOICE
MN663943700Medicaid
CAA78596OtherSTATE MEDICAL LICENSE
MN01-23535OtherMEDICA - PRIMARY
MNHP61533OtherHEALTHPARTNERS
MN1042337OtherPREFERRED ONE
WI43828800Medicaid
MN761T6WIOtherBCBS
WI43828800Medicaid