Healthcare Provider Details

I. General information

NPI: 1619115458
Provider Name (Legal Business Name): MARC NICOLOFF PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2009
Last Update Date: 03/11/2021
Certification Date: 03/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SAINT JOHNS BLVD SUITE 201
MAPLEWOOD MN
55109-1183
US

IV. Provider business mailing address

225 SMITH AVE N SUITE 300
SAINT PAUL MN
55102-2533
US

V. Phone/Fax

Practice location:
  • Phone: 651-747-8500
  • Fax: 651-747-8501
Mailing address:
  • Phone: 651-726-6200
  • Fax: 651-726-6201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: