Provider Demographics
NPI:1861404899
Name:FIFER, NICOLE ELAINE (PAC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ELAINE
Last Name:FIFER
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:ELAINE
Other - Last Name:SCHARRER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA C
Mailing Address - Street 1:PO BOX 45443
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84145-0443
Mailing Address - Country:US
Mailing Address - Phone:904-202-1032
Mailing Address - Fax:904-376-4107
Practice Address - Street 1:1400 BISHOP ESTATES RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32259-4244
Practice Address - Country:US
Practice Address - Phone:904-287-2794
Practice Address - Fax:904-287-5362
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2018-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA200082363AM0700X, 363A00000X
FLPA9108411363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1013510Medicaid
LA57061P855Medicare PIN