Provider Demographics
NPI:1548652100
Name:MAGRANN, NICOLE LISETT (PA-C)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:LISETT
Last Name:MAGRANN
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 1:270 NORTHLAKE BLVD STE 1008
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32701-4335
Mailing Address - Country:US
Mailing Address - Phone:407-834-3300
Mailing Address - Fax:407-834-3800
Practice Address - Street 1:270 NORTHLAKE BLVD STE 1008
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-4335
Practice Address - Country:US
Practice Address - Phone:407-834-3300
Practice Address - Fax:407-834-3800
Is Sole Proprietor?:No
Enumeration Date:2015-02-19
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA057477363AM0700X
FLPA9110925363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical