NPIMap

Individual provider Active NPI

Nicole J Charles, PAC

  • Medical Physician Assistant
  • Waconia, MN
National Provider Identifier
1104008093
Registry record updated Mar 23, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Medical Physician AssistantTaxonomy code 363AM0700X
License
1081 Issued in MN
Practice address
500 S Maple St
Waconia, MN 55387-1752
Phone
(952) 442-2191
Fax
(952) 974-3201
NPI assigned
Dec 3, 2007
Last updated
Mar 23, 2021By the provider in NPPES
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Mar 23, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Medical Physician Assistant 363AM0700X 1081 MN Primary

Addresses

Primary practice location

500 S Maple St
Waconia, MN 55387-1752

Mailing address

4729 County Road 101
Minnetonka, MN 55345-2634
Phone (952) 974-3200

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20080119000009 MN Practitioner - Physician Assistant 0749361434 Reassigns benefits to 3 organizations

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2007
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices
Ridgeview Medical CenterGroup PAC ID 9234041997, 407 clinicians

Practice addresses (Care Compare)

500 S Maple St
Waconia, MN 55387-1752
Phone (952) 442-2191

601 W Chandler St
Arlington, MN 55307-2127
Phone (507) 964-2271

621 S 4TH St
Le Sueur, MN 56058-2203
Phone (507) 665-3375

7907 Powers Blvd
Chanhassen, MN 55317-9502
Phone (952) 934-0570

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
Minnesota Valley Health Center Inc CurrentSince Aug 7, 2025 Accepting new patients
Ridgeview Medical Center CurrentSince Nov 3, 2020 Accepting new patients
Minnesota Valley Health Center Inc Current Accepting new patients
Sibley Medical Center CurrentSince Nov 3, 2020 Accepting new patients
Ridgeview Medical Center CurrentSince Nov 3, 2020 Accepting new patients
Ridgeview Medical Center Past Accepting new patients

Locations

601 W Chandler St
Arlington, MN 55307
Phone (507) 964-2271

7907 Powers Blvd
Chanhassen, MN 55317
Phone (952) 934-0570

111 Hundertmark Rd
Ste 120
Chaska, MN 55318
Phone (952) 856-4001

1805 Hennepin Ave N
Glencoe, MN 55336
Phone (320) 864-3121

621 S 4th St
Le Sueur, MN 56058
Phone (507) 665-3375

4695 Shoreline Dr
Spring Park, MN 55384
Phone (952) 442-7890

500 S Maple St
Waconia, MN 55387
Phone (612) 442-2191

560 S Maple St
Ste 220
Waconia, MN 55387
Phone (952) 442-8011

Organizations & group practices 7

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 6

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1196640000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1616457600000",
    "number": "1104008093",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4729 COUNTY ROAD 101",
            "city": "MINNETONKA",
            "state": "MN",
            "postal_code": "553452634",
            "telephone_number": "952-974-3200",
            "fax_number": "952-974-3201"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "500 S MAPLE ST",
            "city": "WACONIA",
            "state": "MN",
            "postal_code": "553871752",
            "telephone_number": "952-442-2191",
            "fax_number": "952-974-3201"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "CHARLES",
        "first_name": "NICOLE",
        "middle_name": "J",
        "credential": "PAC",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2007-12-03",
        "last_updated": "2021-03-23",
        "certification_date": "2021-03-23",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": "MN",
            "license": "1081",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Waconia, MN

Sources for this page

Verify at the official NPI Registry.