Healthcare Provider Details

I. General information

NPI: 1497930531
Provider Name (Legal Business Name): NICO PA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2008
Last Update Date: 01/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 KIRKWOOD RD 2ND FLOOR
PORT WASHINGTON NY
11050-1437
US

IV. Provider business mailing address

127 S BROADWAY
YONKERS NY
10701-4006
US

V. Phone/Fax

Practice location:
  • Phone: 917-388-7644
  • Fax:
Mailing address:
  • Phone: 917-388-7644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number009001
License Number StateNY

VIII. Authorized Official

Name: NICK N NICOLOFF
Title or Position: SOLE PROPRIETER
Credential:
Phone: 917-388-7644