Provider Demographics
NPI:1144461260
Name:MINSHEW, NICOLE (PA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MINSHEW
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 RIVER PARK PLZ
Mailing Address - Street 2:SUITE110
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76116-0920
Mailing Address - Country:US
Mailing Address - Phone:817-731-1289
Mailing Address - Fax:817-731-1291
Practice Address - Street 1:2550 RIVER PARK PLZ
Practice Address - Street 2:SUITE110
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-0920
Practice Address - Country:US
Practice Address - Phone:817-731-1289
Practice Address - Fax:817-731-1291
Is Sole Proprietor?:No
Enumeration Date:2009-03-19
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06253363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX203461301Medicaid
8L15182Medicare PIN