Healthcare Provider Details

I. General information

NPI: 1598565541
Provider Name (Legal Business Name): DOMINIC JOHN NICOLETTI PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2025
Last Update Date: 03/18/2025
Certification Date: 03/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 JAMES ST
EDISON NJ
08820-3947
US

IV. Provider business mailing address

144 NORTON ST
SOUTH AMBOY NJ
08879-2260
US

V. Phone/Fax

Practice location:
  • Phone: 732-321-7000
  • Fax:
Mailing address:
  • Phone: 732-882-4763
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number25MP00882300
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: