Provider Demographics
NPI:1265685762
Name:ROTA, NICOLE DENISE (PA-C)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:DENISE
Last Name:ROTA
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 1:1125 SE WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99164-0001
Mailing Address - Country:US
Mailing Address - Phone:509-335-3575
Mailing Address - Fax:509-335-8214
Practice Address - Street 1:1125 SE WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99164-0001
Practice Address - Country:US
Practice Address - Phone:509-335-3575
Practice Address - Fax:509-335-8214
Is Sole Proprietor?:No
Enumeration Date:2008-10-28
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-780363AM0700X, 363A00000X
WAPA61529253363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical