Healthcare Provider Details

I. General information

NPI: 1265359210
Provider Name (Legal Business Name): COLE NICHOLSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2026
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 E MAIN ST
BAY SHORE NY
11706-8408
US

IV. Provider business mailing address

31 LOWELL AVE
HOLTSVILLE NY
11742-1518
US

V. Phone/Fax

Practice location:
  • Phone: 631-968-3000
  • Fax:
Mailing address:
  • Phone: 631-445-9988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: