Healthcare Provider Details

I. General information

NPI: 1003027459
Provider Name (Legal Business Name): MARTIN HAYNES NICOL SR. PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2007
Last Update Date: 07/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2367-69 2ND AVE
NEW YORK NY
10035-3108
US

IV. Provider business mailing address

145 REMSEN AVE
BROOKLYN NY
11212-1342
US

V. Phone/Fax

Practice location:
  • Phone: 212-876-2300
  • Fax: 212-369-8209
Mailing address:
  • Phone: 718-467-4280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number003345-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: