Provider Demographics
NPI:1700153640
Name:STOKER, NICOLE MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:STOKER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:DIMITT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:7628 N LA CHOLLA BLVD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85741-4201
Mailing Address - Country:US
Mailing Address - Phone:520-543-0353
Mailing Address - Fax:
Practice Address - Street 1:7628 N LA CHOLLA BLVD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85741-4201
Practice Address - Country:US
Practice Address - Phone:520-543-0353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-21
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5083363A00000X, 363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ682629Medicaid
AZ682629Medicaid
AZZ102176Medicare PIN