Provider Demographics
NPI:1821980608
Name:LANGAN, NICOLE BROOKE (PA-C)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:BROOKE
Last Name:LANGAN
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 1:7114 WOODLORE CT
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48323-4029
Mailing Address - Country:US
Mailing Address - Phone:248-252-3062
Mailing Address - Fax:
Practice Address - Street 1:259 MACK AVE STE 2590
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2427
Practice Address - Country:US
Practice Address - Phone:313-577-1716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-16
Last Update Date:2025-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI390200000X
MI5601013045363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program