Provider Demographics
NPI:1861064735
Name:KREBS, NICOLE REBECCA (PAA-C)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:REBECCA
Last Name:KREBS
Suffix:
Gender:F
Credentials:PAA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 DOCK HILL RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17842-8910
Mailing Address - Country:US
Mailing Address - Phone:570-837-2123
Mailing Address - Fax:570-837-2185
Practice Address - Street 1:409 N 4TH ST
Practice Address - Street 2:
Practice Address - City:SUNBURY
Practice Address - State:PA
Practice Address - Zip Code:17801-1918
Practice Address - Country:US
Practice Address - Phone:570-286-1482
Practice Address - Fax:570-286-5243
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-12
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA062597363A00000X
PAOA005721363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1U7741OtherMEDICARE
PA1039551200001Medicaid