Basic Information
| Provider Information | |||||||||
| NPI: | 1417362534 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JUDGE | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PHD, PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1201 GRAMPIAN BLVD | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSPORT | ||||||||
| State: | PA | ||||||||
| PostalCode: | 177011900 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 700 HIGH ST | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSPORT | ||||||||
| State: | PA | ||||||||
| PostalCode: | 177013100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703212810 | ||||||||
| FaxNumber: | 5703212811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2014 | ||||||||
| LastUpdateDate: | 02/15/2019 | ||||||||
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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 | OA003615 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.