Basic Information
| Provider Information | |||||||||
| NPI: | 1902293830 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DODGE | ||||||||
| FirstName: | NIKOLE | ||||||||
| MiddleName: | RENAE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6804 CECELIA DR | ||||||||
| Address2: | |||||||||
| City: | NEW PORT RICHEY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346534935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7272320644 | ||||||||
| FaxNumber: | 8885460488 | ||||||||
| Practice Location | |||||||||
| Address1: | 379 6TH AVE W | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342058820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417824100 | ||||||||
| FaxNumber: | 9417824101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2015 | ||||||||
| LastUpdateDate: | 06/01/2018 | ||||||||
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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 | PA9108578 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.