Healthcare Provider Details

I. General information

NPI: 1104632108
Provider Name (Legal Business Name): NICOLE WARGO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2024
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 1ST AVE
NEW YORK NY
10029-7494
US

IV. Provider business mailing address

171 E 84TH ST APT 4H
NEW YORK NY
10028-2079
US

V. Phone/Fax

Practice location:
  • Phone: 212-423-6262
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number032842
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: