Provider Demographics
NPI:1861418915
Name:FARO, NICOLE MAREK (MD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MAREK
Last Name:FARO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NIOCLE
Other - Middle Name:MAREK
Other - Last Name:WALTERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2024 58TH ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-1719
Mailing Address - Country:US
Mailing Address - Phone:916-454-0777
Mailing Address - Fax:
Practice Address - Street 1:8110 LAGUNA BLVD
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-7904
Practice Address - Country:US
Practice Address - Phone:916-683-3955
Practice Address - Fax:916-683-3972
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA85741208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI31564Medicare UPIN
CA00A857410Medicare PIN