Healthcare Provider Details

I. General information

NPI: 1982925301
Provider Name (Legal Business Name): NICOLE L DUSENBURY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2010
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 MILLARD ST
DUNDEE NY
14837-9400
US

IV. Provider business mailing address

50 MILLARD ST
DUNDEE NY
14837-9400
US

V. Phone/Fax

Practice location:
  • Phone: 607-243-7881
  • Fax:
Mailing address:
  • Phone: 607-243-7881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA054809
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberAMD -- 581
License Number StateHI
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number014584-1
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA207501
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: