Basic Information
| Provider Information | |||||||||
| NPI: | 1093107641 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WHARTON | ||||||||
| FirstName: | NICOLE | ||||||||
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| OtherLastName: | HWA | ||||||||
| OtherFirstName: | NICOLE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 151 SOUTHHALL LN | ||||||||
| Address2: | STE 300 | ||||||||
| City: | MAITLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327517176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078752080 | ||||||||
| FaxNumber: | 4076503455 | ||||||||
| Practice Location | |||||||||
| Address1: | 1503 BUENOS AIRES BLVD | ||||||||
| Address2: | BLDG 100 | ||||||||
| City: | THE VILLAGES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321596821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3527532812 | ||||||||
| FaxNumber: | 3527535037 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2015 | ||||||||
| LastUpdateDate: | 04/26/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9108349 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 015383600 | 05 | FL | MEDICAID |