Healthcare Provider Details

I. General information

NPI: 1104448489
Provider Name (Legal Business Name): NICHOLAS RUGGIERO PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2020
Last Update Date: 04/08/2021
Certification Date: 04/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 BROOK AVE
STATEN ISLAND NY
10306-4420
US

IV. Provider business mailing address

136 BROOK AVE
STATEN ISLAND NY
10306-4420
US

V. Phone/Fax

Practice location:
  • Phone: 718-619-6124
  • Fax:
Mailing address:
  • Phone: 718-619-6124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number025948
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: