Provider Demographics
NPI:1023419504
Name:NIESE, NICOLE LEIGH (PA-C)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:LEIGH
Last Name:NIESE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 N WYNN RD
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:OH
Mailing Address - Zip Code:43616-1542
Mailing Address - Country:US
Mailing Address - Phone:304-532-0943
Mailing Address - Fax:
Practice Address - Street 1:3028 NAVARRE AVE
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:OH
Practice Address - Zip Code:43616-3308
Practice Address - Country:US
Practice Address - Phone:419-697-6850
Practice Address - Fax:419-697-6861
Is Sole Proprietor?:No
Enumeration Date:2014-09-15
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH004102363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant