Provider Demographics
NPI:1003813197
Name:HUBBARD, NICHOLE A (PA)
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:A
Last Name:HUBBARD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:NICHOLE
Other - Middle Name:ANN
Other - Last Name:BERGMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:100 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-1516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2751 BAY PARK DR STE 303
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:OH
Practice Address - Zip Code:43616-4922
Practice Address - Country:US
Practice Address - Phone:419-693-0711
Practice Address - Fax:419-693-2320
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50001377363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0067932Medicaid
OH12894Medicare UPIN
OH76031Medicare PIN
OH970015389Medicare PIN