Provider Demographics
NPI:1801288311
Name:HAZUKA, NICHOLE WRAE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:NICHOLE
Middle Name:WRAE
Last Name:HAZUKA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:8405 E BASELINE RD STE 104
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-4376
Mailing Address - Country:US
Mailing Address - Phone:480-674-3295
Mailing Address - Fax:725-239-7974
Practice Address - Street 1:8405 E BASELINE RD STE 104
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-4376
Practice Address - Country:US
Practice Address - Phone:480-674-3295
Practice Address - Fax:725-239-7974
Is Sole Proprietor?:No
Enumeration Date:2015-02-21
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO4219363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant