Provider Demographics
NPI:1770909749
Name:FOGT, NICOLE ELIZABETH (PA-C)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:ELIZABETH
Last Name:FOGT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:ELIZABETH
Other - Last Name:LARSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1200 6TH AVE N
Mailing Address - Street 2:CENTRACARE CLINIC
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2735
Mailing Address - Country:US
Mailing Address - Phone:320-656-7020
Mailing Address - Fax:
Practice Address - Street 1:1200 6TH AVE N
Practice Address - Street 2:CENTRACARE CLINIC
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2735
Practice Address - Country:US
Practice Address - Phone:320-656-7020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-13
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11514363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant