Provider Demographics
NPI:1437946381
Name:RODEROS, NICOLE DOMINIQUE (PA-C)
Entity type:Individual
Prefix:
First Name:NICOLE DOMINIQUE
Middle Name:
Last Name:RODEROS
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 1:36456 CHERVIL WAY
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92532-3024
Mailing Address - Country:US
Mailing Address - Phone:951-252-3484
Mailing Address - Fax:
Practice Address - Street 1:36456 CHERVIL WAY
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92532-3024
Practice Address - Country:US
Practice Address - Phone:951-252-3484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-23
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical